Integrated case

management model
 What is ICMM?
Case management is a collaborative process
which assesses, plans, implements, coordinates,
monitors and evaluates options and services to
meet an individuals health needs through
communication and available resources to promote
quality cost-effective outcomes. (CMSA, 2010).
Gronda (2009:8) found that successful case
management support was characterised by a
persistent, reliable, intimate and respectful
relationship and involved comprehensive practical
support.
 Aim

Aim of integrated care as being to

enhance quality of care and quality
of life, consumer satisfaction and
system efficiency for patients with
complex, long-term problems cutting
across multiple services, providers
and settings Kodner and
Spreeuwenberg, 2002, p.757)
 Guiding Principles

Case management guiding principles, interventions, and strategies are targeted at the achievement
of client stability, wellness, and autonomy through advocacy, assessment, planning, communication,
education, resource management, care coordination, collaboration, and service facilitation. They are
based on the needs and values of the client and are accomplished in collaboration with all service
providers. This accomplishes care that is appropriate, effective, client-centred, timely, efficient, and
equitable. Guiding principles are relevant and meaningful concepts that clarify or guide practice.
Guiding principles for case management practice include the following.
Use a client-centric, collaborative partnership approach.
Whenever possible, facilitate self-determination and self-care through the tenets of advocacy, shared
decision-making, and education.
Use a comprehensive, holistic approach.
Practice cultural competence, with awareness and respect for diversity.
Promote the use of evidence-based care, as available.
Promote optimal client safety.
Promote the integration of behavioural change science and principles. Link with community
resources.
Assist with navigating the health care system to achieve successful care, for example during
transitions.
Pursue professional excellence and maintain competence in practice.
Promote quality outcomes and measurement of those outcomes.
Support and maintain compliance with federal, state, local, organizational, and certification rules
and regulations. (CMSA, 2010).
 Primary steps in the case management
process include (Powell & Tahan, 2008):

Client identification and selection: Focuses on identifying clients who would

benefit from case management services. This step may include obtaining
consent for case management services, if appropriate.
. Assessment and problem/opportunity identification: Begins after the
completion of the case selection and intake into case management and occurs
intermittently, as needed, throughout the case.
Development of the case management plan: Establishes goals of the
intervention and prioritizes the clients needs, as well as determines the type of
services and resources that are available in order to address the established
goals or desired outcomes.
Implementation and coordination of care activities: Puts the case
management plan into action.
Evaluation of the case management plan and follow-up: Involves the
evaluation of the clients status and goals and the associated outcomes.
Termination of the case management process: Brings closure to the care
and/or episode of illness. The process focuses on discontinuing case
management when the client transitions to the highest level of function, the best
possible outcome has been attained, or the needs/desires of the client change.
Benefits of the Case Management:

There is evidence that case management can have a

positive impact on care experiences, care outcomes
and, in some instances, service utilisation, when the
approach is appropriately designed and implemented.
Case management works best when it is part of a
wider programme where the cumulative impact of
multiple strategies (rather than a single intervention)
can be successful in improving patient experiences
and outcomes (Powell-Davies et al 2008; Ham 2009).
Integrated delivery systems have led the way in
improving care for people with chronic diseases
(Wales, 2010)
 Mrs Ricardo

LIVES WITH HER

DAUGHTER SARAH WHO
Speaks little
86 year old IS BOTH HER FULL TIME
English CARER AND
INTERPRETER.
 Justification of the relevance of the
model with Mrs. Ricardos case
Special needs for Mrs Ricardo
and Sarah
interpreter
full time carer
difficulty mobilising and needs
specialised transport
GP who home visits and is willing
to take on a patient with such
complex care needs
Reasons/ facts
speaks a little English
86 years old
Parkinsons disease
respiratory problems and heart
failure
exacerbation of acute heart
failure
Sarah is not satisfied with their
current GPs management of Mrs
Ricardos chronic care needs
Justification of the relevance of the
model with Mrs. Ricardos case
Special needs for Mrs Ricardo
and Sarah
interpreter
full time carer
difficulty mobilising and needs
specialised transport
GP who home visits and is willing
to take on a patient with such
complex care needs
Reasons/ facts
speaks a little English
86 years old
Parkinsons disease
respiratory problems and heart
failure
exacerbation of acute heart
failure
Sarah is not satisfied with their
current GPs management of Mrs
Ricardos chronic care needs
 Facilitators& Barriers
Discussion-Facilitators

Integrated case management model

is based on six main principals per
SHASP, any factors (in reference to
Mrs. Ricardos case) that affect any
of these principals may act as a
barrier or a facilitator to providing
care using integrated case
management model
 Discussion-Facilitators & Barriers
Facilitators in case of
Ricardo Facilitators of ICCM

Home visits is a key intervention,

GP visits at home. when addressing frequent hospital
readmission (Wong et al., 2008).It is
difficult for elderly HF patients to visit
clinics, therefore 3home health care
nursing and home visits are important
(van der Wal & Jaarsma, 2008).
Taking part in cardiac
rehabilitation
HF management programmes are
programme following developed to achieve positive effects
hospital readmission. on patient outcomes (Ditewig, Blok,
Havers, & van Veenendaal, 2010).
 Discussion-Facilitators & Barriers
Facilitators in case of
Ricardo Facilitators of ICCM
Reviewing and
changing her
medication regime to Not providing full information on
better control her medications, lead to poor adherence of
the medication regime (Adams, 2010).
heart failure.

Neurologist being
Through investing in multidisciplinary
informed of the teams that consists of primary,
hospital admission. secondary and social care 27%
reduction of total number of bed days
Who also reviewed for emergency admissions have been
reported (Wales, 2010).
and adjusted her plan
for Parkinsons
disease.
 Discussion-Facilitators & Barriers
Facilitators in case of
Ricardo Facilitators of ICCM
Assistance of an
There is evidence to show the value of
interpreter was used multidisciplinary team work in the
to communicate with management of chronic disease in
primary care (Ham, 2010)
Sarah and Mrs.
Ricardo.

Education and It has been found that providing

counselling was given education and counselling improves
adherence to interventions in heart
to Sarah and Mrs. failure patients. (Holst, Willenheimer,
Mrtensson, Lindholm, & Strmberg,
Ricardo at the heart 2007).
failure clinic.
 Discussion-Facilitators &
Barriers
Barriers to integrated case Barriers implementing ICMM
management model of care in Mrs. Ricardos case

Operational Complexity: In case of Ricardo, It will be difficult to implement

ICMM because we need to bring huge change ( in
Health system consists of pre-existing approaches
clinical and management level) in the approaches.
and structures for providing care which may
Her GP, neurologist and other health professional
preclude implementation ICMM. (Maruthappu,
needs to involve
Hasan, & Zeltner, 2015)

Communication Gap: In case of Mrs. Ricardo, Ricardo speak little English

which may hinder the ICMM. In addition, Her GP is
ICCM requires effective communication between
not bring to able to access medical data entered
health professionals, patient and family members.
by neurologist or other health professional or vice
Different infrastructure framework for example IT
versa which creates communication gap.
systems platform hinders the communication of
health professionals.
(Khanassov, Vedel, & Pluye, 2014)
 Discussion-Facilitators &
Barriers
Barriers to integrated case Barriers implementing ICMM
management model of care in Mrs. Ricardos case
Lack of Engagement: In case of Ricardo, her GP appears to have less
engagement on her health management. Due to
Since ICMM needs patient, family member and
insufficient education and support, Ricardo also
health professional involved and integrated with
seems to have less engagement.
each other for the better outcome for the patient,
lack of engagement hinders the effectiveness of
ICMM.
(Overbeck, Davidsen, &
Kousgaard, 2016)
Cost: In this case study, Ricardo needs specialized
vehicle to travel, she needs different health
For ICMM, long-term plan with adequate funding
professionals for her complex care needs in a
must be provided which could be costly
community setting which can be costly.
(Khanassov, Vedel, & Pluye, 2014)
 Conclusion
Integrated case management refers to a
team approach taken to co-ordinate
various services for a specific individual
through a cohesive and sensible plan. All
members of the team work together to
provide assessment, planning,
monitoring and evaluation. The team
should include all service providers who
have a role in implementing the plan,
and whenever possible, the person
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 References
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http://www.cmsa.org/portals/0/pdf/memberonly/standardsofpractice.pdf
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