Case Management in Andalusia

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

Andalusian Regional Government launched in 2002 a case management (CM) programme for people with multiple chronic conditions, disabled and elderly. It was progressively implemented in 4-5 years. Over 300 case managers, linked to PHC teams of the National Health Service, were deployed to care for 7 mio inhabitants. Assessment showed improvements in patients' quality of life and better access to rehabilitation and social services. The programme did not reduce visits to emergencies and to A&E.

Purpose of health policy or idea

A new regional Law and related specific financing has been established in Andalusia for a CM programme aimed to improve the quality of the services delivered to a vulnerable segment of the population. Services for this group of patients have been considered a priority by the Andalusian Departament of Health. Some of these vulnerable patients have difficulties in getting appropriate health, social or rehabilitation care within the traditional model.

Case managers are called to be very active advocating for the most appropriate tailor-made services for this segment of the population. They also coordinate care between different levels of the health system. Case managers are called when a patient with a complex condition is discharged from the hospital to plan the return to home and to facilitate the resources this patient will need. They are to encourage primary care teams to be more proactive in home care, and enable them to increase population coverage and the quality of the service.

Better quality of life and a more adequate use of health services is expected in patients included in the CM programme. Over 300 case managers were deployed through the region. Every Primary Health Care team has a case manager. These teams cover a population of between 25000 and 35000 inhabitants and provide home nursing care to the elderly, disabled and chronic patients. Through a coaching process, the CM should encourage family nurses and family doctors to provide more and higher quality home care services. A higher population coverage is expected.

More than 46.000 assessments have been performed to a selected group of the 7 million inhabitants in the Region.

Main points

Main objectives

• To provide tailor-made services to improve patients' quality of life and better services profile utilization
• To decrease the family carer's overburden
• To decrease the number of emergency hospitalizations and A&E visits
• To facilitate access to specific services such as rehabilitation or social services

Type of incentives

• Additional public funds have been allocated to the CM project
• More skilled nurses of primary care centres have been selected for the CM programme and have been specifically trained

Groups affected

Chronic patients and their families, Regional Department of Health, community nurses

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

CM is a new trend in modern health services based in the development of proactive and intensive services for vulnerable elderly and chronic patients. It identifies patients at risk who need special management and follow-up in order to reduce high intensive use of high cost services. Service must be delivered as close to patient's home as possible.

Nowdays the programme can learn from other international experiences such as the Evercare programme in the UK or Kaiser Permanente in the USA, that were not available when the Andalusian programme was launched. They might adopt those strategies that proved to reduce non-planned and urgent hospitalizations.

Political and economic background

The political stability in the Andalusian regional government allowed maintaining a policy of quality in the services allocated to chronic patients. By a regional law for the protection of vulnerable families, launched in 2002, the government started several measures for helping families to cope with elderly and disabled patients. The Regional Health Department identified an area of improvement in the care of complex chronic vulnerable patients at risk. The strategy wanted to increase home care services coverage in this group of patients. One hundred additional community nurses were introduced every year to the primary care teams, until reaching a total of three hundred for developing CM within the first level of care. This particular initiative has not been followed by the Spanish or by other regional Ministries of Health.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Initiators of idea/main actors

• Regierung

• Leistungserbringer: All are public, linked to the Andalusian Regional Government

• Patienten, Verbraucher

Approach of idea

The approach of the idea is described as:
new: Andalusia is the first Autonomous Community in Spain who developed this new model

Innovation or pilot project

Local level - There are other pilot projects in Catalonia and in other regions of Spain

Stakeholder positions

Community Nurses were reluctant at the beginning because they believed that the Home Care Programme of the Primary Care Centres already covered these population needs. Nevertheless evaluations carried out by the Andalusian Department of Health and the Andalusian Health Service (Servicio Andaluz de Salud, SAS) showed a rather low level of coverage of this high risk population provided by primary health care teams. Data proved that more intensive and extensive home care services for these patients were needed.

Progressively, a collaborative process has been developed for reinforcing the CM activity within the primary care teams. Health authorities executed a proactive policy of change management during these 5 years of the implementation of the programme.

Actors and positions

Regierung
Andalusian Department of Health	sehr unterstützend		stark dagegen
Primary Care Services Directorate	sehr unterstützend		stark dagegen
Leistungserbringer
Primary Care Nurses	sehr unterstützend		stark dagegen
Social Services	sehr unterstützend		stark dagegen
Other Health Services	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patients	sehr unterstützend		stark dagegen
Families	sehr unterstützend		stark dagegen

Influences in policy making and legislation

The Socialist Party is in power in Andalusia for more than 20 years. This stability, and the high level of autonomy in the health sector, allowed the regional government to provide more benefits to the population than other regions of Spain. For instance, citizens have a reduction in pharmacy co-payments and elderly receive additional services. The Regional Government adds extra funds for covering these services. In 2002, Andalusian Health Department launched a new Law called "Decreto 137-2002 de Atencion a las Familias" who established several measures for improving public services to the elderly and disabled people.

Legislative outcome

success

Actors and influence

Regierung
Andalusian Department of Health	sehr groß		kein
Primary Care Services Directorate	sehr groß		kein
Leistungserbringer
Primary Care Nurses	sehr groß		kein
Social Services	sehr groß		kein
Other Health Services	sehr groß		kein
Patienten, Verbraucher
Patients	sehr groß		kein
Families	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

The Andalusian Department of Health has been very supportive in the development of this new policy. Specific funds have been allocated to the programme and the process has been accurately managed. Case managers have been carefully recruited among the best nurses of the primary care tams. The new activity was presented as a professional promotion recognised in the salary. New case managers received a specific training and became experts in the topic. Professional development has been a good attraction focus for recruiting the best nurses.

Monitoring and evaluation

The Spanish Ministry of Health commissioned the Andalusian Public Health School, Granada, with the evaluation of the impact of this new project  Assessment centered on:

• Impact on quality of life
• Care-giving burden
• Service utilization: emergency hospitalization, A&E attendance, home visits
• Use of other services such as: social services and rehabilitation
• Change in the individual's autonomy for coping with the activities of daily living (ADL)

Dimensions of evaluation

Struktur, Prozess, Ergebnis

Results of evaluation

Some positive results have been observed in the comparison of the intervention group with the control one:

• Base-line differences in the functional capacity - significantly lower in the intervention group disappeared at six months.
• At six months, caregiver burden showed a slight reduction in the intervention group whereas it increased notably in the control group.
• Patients in the intervention group received more physiotherapy and, on average, required fewer home care.
• No differences were found in frequency of visits to A&E or in hospital re-admissions.
• Patients in the control group related higher levels of satisfaction.

Expected outcome

The CM Programme did improve quality of life, patient satisfaction and services accessibility and appropriateness but it did not modify the emergency hospital utilization and A&E attendance. CM in Andalusia might reduce hospital service costs if the programme becomes more active in searching high-risk patients in the community and more pro-active in the management of the patients. Current organisation is too reactive. The programme must adopt a more assertive case management as the Evercare programme does in the UK, in order to improve outcomes and reduce hospitalization rates.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Despite the positive outcome of the CM programme, a resistance in the attitude of primary care nursing professional organisations remains. More time is needed for Andalusia citizens to benefit from a reduction in hospital admissions. The project needs to mature and evolve. Prevention of hospital admissions due to the lack of control of chronic diseases must become a priority for both primary care and hospital services in Andalusia. Their CM programme must explore more opportunities in the community for identifying and delivering effective services to these vulnerable patients.

References

Sources of Information

• Morales JM, Gonzalo E, Martin F, Morilla JC, Celdran M, Millan A et al. Effectiveness of a nurse-led case management in Spanish Primary Health Care model. A quasi-experimental, controlled and multicentric study. BMC Health Services Research 2008; 8: 193
• Direccion Regional de Inovacion en Cuidados. Manual Gestion de Casos en Andalucia. SAS: Sevilla, 2007
• Perez R, Lopez S, Lacila M, Rodriguez S. La Enferra Comunitaria de Enlace en el Servicio Andaluz de Salud. Enfermeria Comunitaria 2005; 1: 43-48

Author/s and/or contributors to this survey

Juan Carlos Contel Segura

Nurse Head Manager at Costa de Ponent Primary Health Care Directorate. Associate Professor at Barcelona University.

Empfohlene Zitierweise für diesen Online-Artikel:

Contel Segura, Juan Carlos. "Case Management in Andalusia". Health Policy Monitor, 11/11/2008. Available at http://www.hpm.org/survey/es/a12/1