Which staff improve care for people with long term conditions

Which staff improve care for people with long term conditions

A RAPID REVIEW OF THE LITERATURE
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The government’s commitment to improve care for people with long-term
conditions depends on the ability of the NHS to recruit staff with the
training and skills to deliver services of a high quality. This has been
recognised in the decision to appoint Community Matrons to meet the
needs of people with complex needs, but the workforce implications of
the long-term conditions policy extend well beyond nurses working in the
community. For example, people with long-term conditions can
themselves take on a bigger role in the management of their care, while
teams of staff from different disciplines can contribute to improve
outcomes. Nurses other than community matrons have also taken on a
variety of roles in caring for people with long-term conditions, both in
hospital and the community.
Recognising the complex issues involved in this area of policy and
practice, the Health Services Management Centre (HSMC) at the
University of Birmingham and the NHS Modernisation Agency joined
forces to commission a review of the literature on the workforce
implications of the long-term conditions policy.
This report, written by Dr Debbie Singh, summarises the results of the
review. In brief, the report suggests:
•
there is evidence that peer-led self-management courses can improve
the self-efficacy of people with long-term conditions,
•
there is evidence that GPs and nurses working together in primary
care and teams made up of workers from primary and secondary care
can improve outcomes and service use,
•
there is some evidence that primary care nurse case managers, such
as Community Matrons and specialist nurses, can improve service use
when implemented as part of an integrated programme of care.
On other issues, the report finds either mixed or insufficient evidence
about the role of the workforce. It also emphasises that almost all of the
studies reviewed involved complex interventions that did not isolate the
workforce elements from other service changes. These are important
caveats that need to be borne in mind in reading the review.
HSMC and the NHS Modernisation Agency are making this report
available to support the next stage of implementing the long-term
conditions policy, in particular with a view to assisting NHS organisations
to make evidence-based decisions about future workforce needs.
Chris Ham
Professor of Health Policy and Management
Health Services Management Centre
University of Birmingham
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This rapid review was commissioned by the NHS Modernisation Agency and the
University of Birmingham Health Services Management Centre. We would like to thank
Sue Roberts, Stirling Bryan, and David Colin Thome for their comments on an early draft.
© 2005 by the author and publishers
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Supporting
People with Long-term Conditions sets out the
government’s plans to help people with long-term medical conditions
live healthy lives. Free courses to help people care for themselves will
be expanded throughout England, teams of staff will be encouraged to
work together to support people with long-term conditions, and
specialist nurses known as Community Matrons will support those with
the most complex needs. All of these initiatives have implications for
workforce development and the training of staff in health, social
services, and allied professions.
While evidence is growing about the initiatives that most improve the
satisfaction, quality of life, and health of people with long-term
conditions, less is known about the implications of these programmes
for staff development and training. Therefore this review focuses on the
staff involved in initiatives to improve chronic care. It collates evidence
about:
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−
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the people who provide self-management education courses,
innovative roles for nurses in primary care and in hospital,
the impact of teams of professionals from different disciplines,
and the varying staff who work as case managers.
The review is based on 172 studies. To identify these studies, ten
electronic databases were searched for reports that explicitly
described staff roles or compared the effects of different types of
professionals on people’s experiences, health, or their use of services
and resources. Experts in the field and authors of identified papers
were contacted and websites and reference lists were searched for
additional studies and unpublished material. Systematic reviews and
randomised trials were prioritised, but other studies were included if
there were no randomised trials about a specific topic. Studies in a
language other than English were translated, by the original authors
where possible.
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Self-management is a key component of many initiatives to improve
care for people with long-term conditions. A number of selfmanagement initiatives exist, including technologies to assist with self
monitoring, accessible information and support services, and courses
to help people learn more about their condition and care. These
courses are often referred to as ‘self-management education.’
An example of self-management education is the NHS Expert Patients
Programme which is taught largely by lay tutors, living themselves with
long-term conditions. This course, based on a model developed in the
United States, brings together people with different types of long-term
conditions for six weekly sessions. Courses have also been developed
for people with particular types of conditions, such as diabetes and
arthritis.
Self-management education courses have been facilitated by people
with long-term conditions, primary care professionals, hospital staff,
and multidisciplinary teams.
We identified 21 studies that explicitly described different selfmanagement course educators, or compared the effects of selfmanagement courses run by professionals versus lay people with longterm conditions. Many other studies of self-management education
exist, but do not describe in detail the personnel working as educators.
The totality of evidence suggests:
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There is good evidence that self-management courses can improve
the self-efficacy and confidence of people with long-term
conditions.
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There is less evidence comparing courses run by people with longterm conditions versus professionals or comparing courses run by
staff from different disciplines. The evidence that does exist
suggests that courses led by peers are equally efficacious to
courses facilitated by professionals.
?
In addition to peer–led courses, we identified studies of courses
run by primary care nurses, primary care teams, hospital teams,
pharmacists, and teachers. There was insufficient evidence to
conclude that some types of staff run self-management courses
more effectively than other types of professionals.
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A large number of disease management programmes are implemented
with the aid of nurses. These may be specialist nurses, who focus
particularly on people with one or more long-term conditions, or more
generalist primary care or hospital nurses.
We identified 53 studies that described innovative roles for nurses
caring for people with long-term conditions, or compared the care
offered by nurses with care from other professionals. Many other
studies of nurse-led care exist, but these did not explicitly define the
role of nurses of provide comparative data.
The totality of evidence suggests:
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There is good evidence that nurses who specialise in a particular
long-term condition, either in hospital or in the community, can
help improve the health of people with long-term conditions and
their use of health services.
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Clinics run by specialist nurses have benefits for patient
satisfaction, experience, and some clinical outcomes, and may
reduce healthcare costs.
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There is insufficient evidence about new roles for hospital nurses.
Studies that substituted hospital nurses for roles traditionally filled
by doctors generally found little evidence of a direct effect on
health or resource use.
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However, follow up after discharge by hospital nurses was
associated with improved health for people with long-term
conditions and fewer hospital readmissions.
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There is mixed evidence about the benefits of nurses in primary
care. Studies generally found that primary care nurses can provide
equivalent care to that traditionally provided by general
practitioners. However, this may or may not improve the health and
wellbeing of people with long-term conditions.
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There is some evidence that primary care nurses who visit people
at home may improve clinical outcomes and reduce the use of
other health services.
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Another key development to improve care for people with long-term
conditions involves teams of professionals from different disciplines
working together. These teams may be based in hospital, in outpatient
settings, in primary care, or spanning the bounds of primary and
secondary care. Teams that incorporate personnel from social
services, the voluntary sector, and community groups are increasingly
common, although less evidence exists about the effects of these types
of teams.
We identified 64 studies that described multidisciplinary teams to help
people with long-term conditions and outlined the exact staff contained
in these teams. Other studies of multidisciplinary teams exist, but do
not focus on who makes up the teams or what their roles are.
The totality of evidence suggests:
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There is evidence that general practitioners and nurses working
together in primary care can improve people’s self-efficacy and
their health.
5
There is good evidence that teams made up of workers from
primary and secondary care can have a positive effect on care
processes, clinical outcomes, and service use. Commonly these
teams involve hospital and primary care nurses, general
practitioners, and specialists such as dieticians.
?
There is mixed evidence about combined teams of mental health
workers and primary care staff. Some studies found that
collaborative care improves quality of life and depression, whereas
others found that combined working is more expensive and has few
tangible benefits.
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There is limited evidence about strategies to integrate social and
medical care, but the few available studies suggest that teams
made up of social and health professionals can improve clinical
outcomes.
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There is evidence that adding a pharmacist to primary care teams
can help people receive more effective treatment.
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There is good evidence that care from multidisciplinary teams in
hospital can reduce the length of hospital stay and may reduce
readmissions.
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Other than case managers, we identified no high quality studies
about particular staff roles that may help to interface between
primary and secondary care or promote joint working strategies
between health and social care.
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Case management involves co-ordinating care for a person with longterm conditions and following them up regularly. This may involve coordinating care from general practitioners, hospital specialists, and
social care, and supporting people and their families to manage their
own conditions.
Case managers are often nurses based in primary care or, less
frequently, in hospital. In England, Community Matrons are an example
of nurse practitioners who are trained to provide one-to-one support for
a caseload of between 30 and 60 people each. Case management has
also been conducted by multidisciplinary teams, pharmacists, and
mental health staff.
We identified 34 studies that described different staff who have taken
on the role of case managers. A large number of other studies
described and evaluated case management programmes but did not
make clear the exact staff taking on the case manager role.
The totality of evidence suggests:
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The majority of studies have focussed on primary care nurses as
case managers. These nurses may be based within primary care
practices or may be roving community nurses. There is some
evidence that primary care nurse case managers, such as
Community Matrons, can improve clinical outcomes and reduce
use of health services, especially for people with the most complex
needs. However, other studies have found no benefit from case
management by primary care nurses. Evidence from the United
Kingdom is currently sparse.
?
Hospital nurses sometimes act as case managers, especially
during discharge and hospital follow up. There is mixed evidence
about the benefits of this approach. Some studies have found
improved outcomes and others have found no significant
difference from usual care.
?
Psychiatric teams and mental health workers have also
implemented case management programmes. Evidence about the
effectiveness of these approaches is mixed. Some large reviews
have concluded that case management by mental health
specialists has limited benefit, others have concluded that case
management by community or hospital-based mental health
workers can improve the quality of care for people with long-term
mental illnesses.
?
Other staff who have taken on a case management role include
pharmacists and community workers. There is insufficient
information about the effects of these models of case management.
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There is emerging evidence about the possibility of recruiting
people with long-term conditions as case managers. Although the
evidence is sparse, those studies that exist suggest that the
concept of peer case managers could be explored further.
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When interpreting the findings of the review, it is important to bear in
mind that almost all of the studies involved complex interventions. In
very few studies were different personnel the only thing compared.
New staff roles are usually accompanied by different service
processes, IT systems, and philosophies. Although this evidence
review focused on the workforce, almost none of the included studies
isolated workforce elements from other important service changes. For
instance, in literature about self-management education, the content
and style of the programme is rarely isolated from the personnel who
deliver it.
The review found little evidence that one type of staff is more effective
than another professional group in most instances. However, a lack of
comparative evidence does not mean that there are no differences
between various types of professionals. Nor does a lack of research
about a particular staff group mean that this group are not effective.
It is also important to emphasise that the context in which staff changes
take place has an impact on the outcomes. Much of the available
evidence is sourced from the United States or Europe, which have very
different healthcare economies and styles of working to the United
Kingdom.
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The findings of this rapid review suggest that:
− Nurses have a central role to play in initiatives to improve care
for people with long-term conditions, whether in primary or
secondary care, as case managers, or as specialist nurses. The
available evidence suggests that in most instances nurses
provide care that is at least as effective as the care provided by
doctors, and often patients are more satisfied with the care
provided by nurses. This suggests that the current focus in
England on providing targeted nurse-led support is justified.
− Involving people with long-term conditions as part of the team,
either as peer educators or as peer case managers, may have
significant benefits. It may be desirable to investigate whether
there is any scope to involve peers in case management roles in
the United Kingdom.
− Case managers aim to co-ordinate services and to provide an
interface between primary and secondary care, and between
health and social services. The majority of evidence does not
focus on the extent to which case managers, often nurses based
in primary care, have achieved this interface. Nor is the
evidence about the benefits of case management unequivocal.
This suggests that case management should be invested in as
one component of a broader disease management strategy.
There is evidence that many initiatives other than case
management can significantly improve health and reduce
resource use. Staff could be trained in these other initiatives as
well, rather than focusing on case management alone.
− Apart from positions which involve advanced clinical
knowledge, there is no evidence to suggest that one type of staff
is any better than another type for delivering care for people
with long-term conditions. Upskilling a wide variety of staff such
as nurses, health visitors, social workers, and mental health
workers may be a feasible way of expanding the chronic care
workforce. However few studies have explicitly compared the
relative merits of these staff groups.
− In England, a ‘whole systems’ approach to chronic care is
gaining popularity. There is insufficient evidence about the best
strategies to foster collaboration between health and social
services, or about staff roles that may facilitate these links,
however. A number of joint working initiatives are currently
underway, so more evaluation of the processes involved in these
initiatives and core staff competencies may be warranted.
− As there is little evidence to recommend one professional group
over another in most situations, people developing new services
for and with people with long-term conditions could focus on
identifying particular needs and service gaps; outlining the
competencies required to meet these needs; and then
considering the best people to meet these needs (either from a
new workforce or from the current workforce with further
training). Solely ‘upskilling’ current staff is unlikely to meet the
complex needs of people with long-term conditions.
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CONTENTS
INTRODUCTION
Introductory overview
Collating available evidence
Caveats
1
3
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SELF-MANAGEMENT EDUCATORS
What are self-management educators?
What do we already know?
What does this review add?
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People with long-term conditions
Primary care nurses
Primary care teams
Hospital staff
Other educators
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EXPANDING NURSING ROLES
What are the roles of nurses?
What do we already know?
What does this review add?
Specialist nurses
Specialist nurse-led clinics
Hospital nurses
Follow-up by hospital nurses
Primary practice nurses
Follow-up by nurses in primary practice
Nurse home visits
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MULTIDISCIPLINARY TEAMS
What are multidisciplinary teams?
What do we already know?
What does this review add?
Primary care nurses and doctors
Pharmacists and primary care
Other primary care teams
Mental health teams and primary care
Hospital teams
Primary and secondary care
Social and medical care
Working with community groups
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CASE MANAGERS
What are case managers?
What do we already know?
What does this review add?
Primary care nurses
Primary care teams
Hospital nurses
Other hospital staff
Psychiatric teams or specialists
Peer case managers
IMPLICATIONS FOR WORKFORCE DEVELOPMENT
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Six out of ten adults in England report having at least one long-term
medical condition such as diabetes, heart failure, arthritis, and
asthma.1 The number of people with long-term conditions is rising in
both the developed and developing worlds, and these people need
increasing support from health and social care systems.2 In Britain 80%
of primary care consultations and two thirds of emergency hospital
admissions are related to long-term conditions.1 People with long-term
conditions often suffer from more than one condition, making their care
even more complex.
Given the increasing number of people affected by long-term conditions
and the impact on health and social care services, a number of
initiatives have been implemented to improve the effectiveness and
efficiency of the care available. In England, initiatives include the
development of National Service Frameworks to support people with
long-term conditions, trials of new care management strategies, and
Public Service Agreement targets.
Supporting People with Long-term Conditions, published January 2005,
set out the government’s plans to help people with long-term conditions
live healthy lives.3 It outlined how the self-management Expert Patients
Programme will be expanded throughout England; how specialist
nurses (Community Matrons) will support people with complex
conditions; and how teams of staff will be encouraged to work together
with people with long-term conditions and their families.
All of these initiatives have implications for workforce development and
the training of staff in health, social services, and allied professions.
However, while evidence is growing about the most effective initiatives
to improve the satisfaction, quality of life, and health outcomes of
people with long-term conditions, less is known about the implications
of these programmes for staff recruitment and training.
Therefore, the University of Birmingham Health Services Management
Centre and the NHS Modernisation Agency reviewed the evidence
about the personnel providing some of the key models of care for
people with long-term conditions.
1
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Chronic Disease Management: A Compendium of Information. London: Department of
Health, 2004.
Innovative Care for Chronic Conditions. Building Blocks for Action. WHO, 2002.
Supporting People with Long Term Conditions. An NHS and Social Care Model to Support
Local Innovation and Integration. London: The Stationery Office, 2005.
1
The objective of this rapid review was to assess:
What key staff have been used to provide innovative care
for people with long-term conditions and what is the
evidence that these staff make a difference?
The review focussed on the personnel involved in providing three
components of the healthcare delivery system outlined in Supporting
People with Long Term Conditions:3
−
supported self-management for the majority of people with longterm conditions (focussing on the facilitators of self-management
education courses).
−
disease management for people at high risk of complications and
service use (specifically the role of specialist nurses and
multidisciplinary teams),
−
and case management for people with highly complex needs
(looking at staff who have taken on the role of case managers such
as hospital and primary care nurses),
In addition, the review examined whether there was any evidence of
staff roles that may help to link these three components, particularly
strategies to interface between primary and secondary care and joint
working strategies between health and social care.
Staff components summarised in this review
About 75% of people with long-term
conditions merely need support to
manage their condition themselves
People at higher risk need
specialist disease
management as well
Case management
is for a small
number with
very complex
needs
This review
focuses on the
staffing of selfmanagement
education
courses
This review
focuses on the
role of nurses
and on multidisciplinary
teams
This review
focuses on
the types of
staff who
work as case
managers
2
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The review summarises published primary research and selected
unpublished literature. To collate evidence, one reviewer searched
MEDLINE, Embase, ERIC, the Science Citation Index, the Cochrane
Library and Controlled Trials Register, PsychLit, HealthStar, the WHO
library, Health Management Information Consortium, Sigal, reference
lists of identified articles and reviews, and the websites of relevant
agencies for information available as at June 2005. Experts in the field
and original authors were contacted and relevant journals were hand
searched for additional studies. Documents available in a language
other than English were translated, where possible by the original
authors.
Search terms included combinations of: workforce, staff, personnel,
layperson, nurse, case management, case manager, patient, specialist,
doctor, social care, pharmacist, social worker, psychologist,
psychiatrist,
chronic,
long-term,
asthma,
diabetes,
health,
hypertension, arthritis, cardiac, heart failure, stroke, dementia, mental
health,
depression,
self-management,
education,
team,
multidisciplinary, interdisciplinary, partnership, shared care, joint
working, collaborative, disease management, care management, and
associated synonyms. Mesh terms and expanded keyword searches
were used where available.
To be eligible for inclusion in the review, studies had to:
• be primary research or systematic reviews,
• be published
organisations,
or
readily
available
online
or
from
relevant
• be available in any language,
• be available in abstract, journal article, or full report form,
• have been prepared within the past 20 years,
• include some participants with any long-term medical condition that
cannot currently be cured, but which is not usually immediately lifethreatening (for example, diabetes, asthma, arthritis, heart failure,
chronic back pain, chronic obstructive pulmonary disease, renal
disease, depression, and dementia),
• describe the staffing model used in a way that was detailed enough
to ascertain exactly which types of staff were involved and what role
they had in the intervention,
• and provide data about outcomes relating to patient experiences,
staff experiences, quality of care, clinical outcomes, or resource
impacts.
Studies of terminal illnesses such as cancer and HIV / AIDs were not
included in this review. Studies that described general initiatives such
as ‘multidisciplinary teams,’ but which did not provide details of the
exact staff and strategies involved were excluded from the review.
3
In the analysis, priority was given to systematic reviews and
randomised trials. However, in instances where randomised trials were
not available, studies lower in the ‘hierarchy of evidence’ were
included. Using this hierarchy of evidence allowed the reviewers to
focus on the highest quality studies of relevance rather than the many
thousands of less rigorous studies, whilst not excluding studies where a
paucity of evidence exists. Studies included in meta-analyses or
systematic reviews described in this overview are not reported again
separately.
In total, summaries of 28,355 documents were assessed for relevance
by two reviewers. Repeated reports of the same trials and papers that
did not contain primary or secondary information about the effects of
staff initiatives were discarded, leaving 4,746 documents to be
assessed in full. Two reviewers examined these studies independently
for relevance and quality using a validated scale.
One hundred and seventy-two studies met the inclusion criteria outlined
above and are summarised in this overview. In addition, reviews
summarising what we already know about each topic were
incorporated for illustrative purposes.
Studies included in the review
28,355 potential reports were identified
through database, online, and hand searching
23,731 abstracts were discarded
because they did not meet the
inclusion criteria
4,746 citations were identified
for full text appraisal for
relevance and quality
3,958 studies were excluded
because they did not describe the
exact staff involved
505 studies were excluded if they
did not provide any information
about outcomes of interest
111 studies were excluded
because they were repeated
studies or included in reviews
172 papers were accepted for
inclusion in the review, and
data were extracted from each
One reviewer extracted data about staff characteristics, country of
origin, participant and disease characteristics, outcomes, and
publication details. All studies were checked for consistency and
accuracy by a second reviewer. Disagreements were resolved by
consensus.
4
To synthesise the evidence, one reviewer grouped studies according to
topic areas and outcomes, and provided a narrative summary of key
trends. Meta-analysis was not possible given the heterogeneity of the
topic areas, study designs, and participants included. Instead the
reviewer focussed on drawing out key findings about the types of staff
providing interventions, and any evidence of effects using content
analysis and narrative synthesis.
The review describes staff working with people with long-term
conditions generally, rather than evidence about approaches to
specific conditions. Studies of people with particular types of
conditions are provided as examples, however.
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A summary of the evidence is presented overleaf. Information about
people who have run self-management education courses is
summarised first, followed by evidence about specialist nurses and
multidisciplinary care, and concluding with evidence about staff who
have worked as case managers.
Before summarising the evidence, however, it is important to raise the
following key caveats for readers to bear in mind when interpreting the
findings.
Almost all of the studies included complex interventions. In very few
studies were different personnel the only thing compared. New staff
roles are usually accompanied by different service processes,
information systems, and philosophies. Although this evidence review
focused on the workforce, almost none of the included studies isolated
workforce elements from other important service changes. For
instance, in literature about self-management education, the content
and style of the programme is rarely isolated from the personnel who
deliver it.
The review found little evidence that one type of staff is more effective
than another professional group in most instances. However, a lack of
comparative evidence does not mean that there are no differences
between various types of professionals. Nor does a lack of research
about a particular staff group mean that this group are not effective or
are not involved in providing care for people with long-term conditions.
It is also important to emphasise that the context in which staff changes
take place has an impact on outcomes. Much of the available evidence
is sourced from the United States or Europe, which have very different
healthcare economies and styles of working to the United Kingdom.
This means that while we can draw inferences about the merits of
different workforce developments from the evidence summarised
overleaf, we can not assume that outcomes would be the same when
transferred to another context.
On a related note, many studies compare an intervention with ‘usual
care.’ What makes up ‘usual care’ in one country or location may be
very different from usual care in another context. Often studies do not
define the components of usual care in any detail, however.
5
SELF-MANAGEMENT EDUCATORS
This section describes:
−
the concept of self-management
education,
−
general evidence about the effects of
self-management education,
−
and the people who have been involved
in delivering self-management
education.
Self-management
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The Department of Health’s strategy for improving the lives of people
with long-term conditions is based on the principle that these people
know as much or more about their illness and their needs as health and
social care professionals.
About three quarters of people with long-term conditions do not need
specialist one-to-one management from health and social care
professionals on an ongoing basis. Instead, they manage their
conditions themselves, perhaps with annual reviews from their general
practitioner.
There are a range of ways that health and social services can help
people manage their own conditions including providing written, verbal
and online information; teaching people to manage their own care; and
providing equipment to help people monitor and identify their
symptoms. The Department of Health drew together examples of a
range of self-management support services in England and concluded
that these initiatives can make a real difference to people’s physical
and mental wellbeing.4
Educational sessions to help people with long-term conditions learn
about their condition and how to manage it better have gained
increasing popularity in recent years. Some educational programmes
provide information about long-term conditions themselves. Other
programmes aim to help people learn how to manage their care more
effectively, including when to use different healthcare services and how
to communicate with professionals. This type of education is generally
known as ‘self-management education.’
Self-management education can be delivered in group sessions, one-toone, by post, by video, or by computer. Group courses are the focus of
this review. Rehabilitation programmes were not considered.
4
Self Care Support: A Compendium of Practical Examples Across the Whole System of Health
and Social Care. Department of Health, 2005.
6
There are two main types of self-management education courses. Some
courses are for people with specific long-term conditions, such as
arthritis. Others target people with any long-term condition(s).
In the United Kingdom, the Expert Patients Programme is an example of
generic self-management education. Free courses are provided by the
NHS and facilitated largely by people with long-term conditions.
Courses usually comprise six weekly sessions lasting two and a half
hours each. Each group has between 8 and 16 participants. Topics
include ‘breaking the symptom cycle,’ diet, exercise, communication,
medication, and pain management.5
Self-management educators may be either professionals or laypeople.
Whatever the case, the role of the self-management educator is to plan
and deliver courses for people with long-term conditions, often
following a standardised manual.
Example of a self-management education course
The charity Arthritis Care has been running free self-management
courses led by people with arthritis for a decade. Arthritis Care’s selfmanagement course was based on the Chronic Disease SelfManagement Course model developed in the United States during the
1980s.
The course aims to enable adults with arthritis to manage their lives
more effectively. Most participants complete the entire six-week
course. Over six sessions of about two and a half hours each, the
course:
−
−
−
−
−
discusses myths about arthritis,
describes relaxation techniques,
draws up exercise programmes,
helps people communicate better with their doctor,
shows people what they can do for themselves.
The course comprises discussions, brainstorming sessions, and brief
lectures. Participants draw up weekly action plans to help them take
more control of their lives.
Other organisations have also introduced self-management courses.
5
The Expert Patient: A New Approach to Chronic Disease Management for the 21st
Century. London: Department of Health, 2001.
7
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A great deal has been written about the effects of self-management
education courses. This section provides examples of studies that
summarise what we know about self-management educators in
general. It does not summarise all available evidence on this topic.
The Expert Patients Programme is based on a course developed by
Stanford University Medical School in California for people with
arthritis. This programme was developed into the Chronic Disease
Self-management Course, a generic educational programme for
people with long-term conditions (rather than being specific to a
particular type of disease). More than 100 studies of variations of this
course have been undertaken throughout the world. Most studies
have been conducted United States, although there is also evidence
from the UK,6,7 Taiwan,8 China,9 Hong Kong,10 New Zealand,11
Canada,12,13 and Norway,14 amongst others.
Survey and telephone interviews with trainers and primary care trust
staff in sites piloting the Expert Patients Programme in the UK found
that people who have direct contact with recruiting patients to
courses and those delivering courses thought that the programme
was an effective and innovative means of managing chronic
conditions. Initial implementation of the programme posed significant
practical challenges, however.15
There are many different types of self-management education
programmes. Not all are based on the Chronic Disease Selfmanagement / Expert Patients Programme model. Some programmes
target people with particular long-term conditions, rather than
working with people with many different types of conditions.
6
7
8
9
10
11
12
13
14
15
Osman LM, Calder C, Godden DJ et al. A randomised trial of self-management planning
for adult patients admitted to hospital with acute asthma. Thorax 2002; 57(10): 869-74.
The British Liver Trust. Living a Healthy Life with Long Term Illness. Leland Stanford
Junior University, 1999.
Chiang LC, Huang JL, Yeh KW, Lu CM. Effects of a self-management asthma educational
program in Taiwan based on PRECEDE-PROCEED model for parents with asthmatic
children. J Asthma 2004; 41(2): 205-15.
Lorig KR, Sobel DS, Stewart AL et al. Evidence suggesting that a chronic disease selfmanagement program can improve health status while reducing utilization and costs: A
randomized trial. Med Care 1999; 37(1): 5-14.
Choy DK, Tong M, Ko F et al. Evaluation of the efficacy of a hospital-based asthma
education programme in patients of low socio-economic status in Hong Kong. Clin Exp
Allergy 1999; 29(1): 84-90.
Wright SP, Walsh H, Ingley KM et al. Uptake of self-management strategies in a heart
failure management programme. Eur J Heart Fail 2003; 5(3): 371-80.
LeFort SM. A test of Braden's Self-Help Model in adults with chronic pain. J Nursing
Scholarship 2000; 32(2): 153-60.
Bourbeau J, Julien M, Maltais F et al. Reduction of hospital utilization in patients with
chronic obstructive pulmonary disease: a disease-specific self-management intervention.
Arch Intern Med 2003; 163(5): 585-91.
Gallefoss F. The effects of patient education in COPD in a 1-year follow-up randomised,
controlled trial. Patient Educ Couns 2004; 52(3): 259-66.
Kennedy A, Gately C, Rogers A. National Evaluation of Expert Patients Programme.
Assessing the Process of Embedding EPP in the NHS. Preliminary Survey of PCT Pilot
Sites. National Primary Care Research and Development Centre, 2004.
8
For instance, DAFNE (Dose Adjustment For Normal Eating) is a
programme specifically for people with diabetes. DAFNE involves
structured training in intensive insulin therapy and self-management.
People with type 1 diabetes are taught to match their insulin dose to
food intake on a meal-by-meal basis. Initial evidence suggests that
this self-management programme is associated with improved quality
of life, satisfaction with treatment, and reduced blood glucose
levels.16 It may also have some cost savings, though most research
focuses on short timescales.17
The National Institute for Clinical Excellence (NICE) has developed
guidelines about patient education models for people with diabetes,
including self-management education. Following a systematic review,
NICE concluded that structured patient education should be made
available to all people with diabetes at the time of initial diagnosis and
on an ongoing basis, based on regular needs assessment. NICE
concluded that there is insufficient evidence to recommend specific
education types or frequencies. However, they suggested that
educational interventions should be provided by a trained
multidisciplinary team to groups of people with diabetes, unless group
work is considered unsuitable for an individual. Educational
programmes should use a variety of techniques to promote active
learning (engaging individuals and relating the content to personal
experience), and should be integrated into routine diabetes care.18
There is little research assessing whether one type of selfmanagement programme is more effective or better received than
another. However, reviews of the evidence-base generally support
the conclusion that self-management programmes, in whatever form,
have positive effects on people’s satisfaction and feelings of
control.19,20,21 For example, a meta-analysis of 82 studies found that
self-management education improved knowledge and self-care
behaviour in adults with diabetes.22
Similarly, there is evidence that people with arthritis taking part in
self-management programmes feel more confident in their abilities to
manage and control their symptoms, feel less anxious about their
disease, and may visit the doctor less frequently.23,24,25,26
16
17
18
19
20
21
22
23
24
25
26
The Expert Patient: A New Approach to Chronic Disease Management for the 21st
Century. London: Department of Health, 2001.
Shearer A, Bagust A, Sanderson D, et al. Cost-effectiveness of flexible intensive insulin
management to enable dietary freedom in people with Type 1 diabetes in the UK.
Diabetic Medicine 2004; 21(5): 460-7.
National Institute for Clinical Excellence. Guidance on the use of patient-education models
for diabetes. London: NICE, 2003.
Barlow JH et al. Self-management Literature Review. Psychosocial Research Centre,
Coventry University, 2000.
Barlow JH, Wright CC, Sheasby A et al. Self-management approaches for people with
chronic conditions: a review. Patient Ed Couns 2002; 48; 177-87.
Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic
disease in primary care. JAMA 2002; 288(19): 2469-75.
Brown SA. Studies of educational interventions and outcomes in diabetic adults: a metaanalysis revisited. Patient Educ Couns 1990; 16(3): 189-215.
Barlow JH, Turner A, Wright CC. Sharing, caring and learning to take control: selfmanagement training for people with arthritis. Psy, Health Med 1998; 3(4): 387-93.
Barlow JH, Turner A, Wright CC. Long-term outcomes of an arthritis self-management
programme. Brit J Rheumatology 1998; 37: 1315-9.
Barlow JH, Turner A, Wright CC. A randomised controlled study of the arthritis selfmanagement programme in the UK. Health Ed Res 2000; 15(6): 665-80.
Barlow JH, Turner A, Wright C. Patient education for people with arthritis in rural
communities: the UK experience. Patient Ed Couns 2001; 44: 205-14.
9
The impact of self-management courses on clinical outcomes is less
clear. A systematic review collated 71 trials of self-management
education for people with long-term conditions. The reviewers found
that people with diabetes participating in self-management education
had improved glycaemic control and blood pressure. People with
asthma experienced fewer attacks after self-management education.
Arthritis self-management education programmes had no significant
clinical effects. The authors concluded that self-management
education programmes may have small to moderate effects for people
with selected long-term conditions. They noted, however, that study
methods varied widely and were not of the highest quality.27 Many
other systematic reviews have drawn similar conclusions.28,29,30,31, 32, 33,
34,35
Although the clinical benefits of self-management education are
uncertain, there is evidence that these programmes can reduce the
use of healthcare resources and subsequent healthcare costs. For
instance, it has been suggested that self-management education
programmes may reduce visits to health professionals by up to
80%.36,37 Visits to general practitioners may decrease by up to two
fifths.38,39,40,41 Randomised trials in the UK also suggest that selfmanagement education can reduce hospital readmissions and reduce
healthcare expenditure.42,43
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
Warsi A, Wang PS, LaValley MP et al. Self-management education programs in chronic
disease: a systematic review and methodological critique of the literature. Arch Intern
Med 2004; 164(15): 1641-9.
Norris SL, Lau J, Smith SJ et al. Self-management education for adults with type 2
diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002; 25(7):
1159-71.
Bernard-Bonnin AC, Stachenko S, Bonin D et al. Self-management teaching programs
and morbidity of pediatric asthma: a meta-analysis. J Allergy Clin Immunol 1995; 95(1 Pt
1): 34-41.
Wolf FM, Guevara JP, Grum CM, et al. Educational interventions for asthma in children.
Cochrane Database Syst Rev 2003; (1): CD000326.
Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self
management of asthma in children and adolescents: systematic review and metaanalysis. BMJ 2003; 326(7402): 1308-9.
Norris SL, Nichols PJ, Caspersen CJ et al. Increasing diabetes self-management education
in community settings. A systematic review. Am J Prev Med 2002; 22 (4 Suppl): 39-66.
Norris SL, Lau J, Smith SJ et al. Self-management education for adults with type 2
diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002; 25(7):
1159-71.
Lorig K. and Holman H. Arthritis self-management studies. A twelve year review. Health
Ed Quart 1993; 20: 17-28.
Warsi A, LaValley MP, Wang PS et al. Arthritis self-management education programs: a
meta-analysis of the effect on pain and disability. Arthritis Rheum 2003; 48(8): 2207-13.
Barlow JH, Williams B, Wright CC. Instilling the strength to fight the pain and get on with
life: learning to become an arthritis self-manager through an adult education programme.
Health Ed Res 1999; 14(4): 533-44.
Cole JD. Psychotherapy with the chronic pain patient using coping skills development:
outcome study. J Occ Health Psy 1998; 3(3): 217-26.
Lorig K, Holman HR. Long-term outcomes of an arthritis self-management study: effects
of reinforcement efforts. Soc Sci Med 1989; 29(2): 221-4.
Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation of peak flow and symptoms
only self management plans for control of asthma in general practice. BMJ 1990;
301(6765): 1355-9.
Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self
management in patients with chronic arthritis has sustained health benefits while
reducing health care costs. Arth Rheum 1993; 36(4): 439-46.
Fries JF, Carey C, McShane DJ. Patient education in arthritis: randomized controlled trial
of a mail-delivered program. J Rheumatology 1997; 24(7): 1378-83.
Kennedy A, Nelson E, Reeves D et al. A randomised controlled trial to assess the impact
of a package comprising a patient-orientated, evidence-based self-help guidebook and
patient-centred consultations on disease management and satisfaction in inflammatory
bowel disease. Health Technol Assess 2003; 7(28): 1-113.
Osman LM, Calder C, Godden DJ et al. A randomised trial of self-management planning
for adult patients admitted to hospital with acute asthma. Thorax 2002; 57(10): 869-74.
10
Other evidence is contradictory. A systemic review of nine trials of
self-management education versus usual care for people with chronic
obstructive pulmonary disease found that self-management education
increased courses of oral steroids and antibiotics for respiratory
symptoms, but had no effect on hospital admissions, emergency
department visits, days lost from work, or lung function.44
Similarly, an evaluation of self-management courses facilitated in the
UK by volunteer tutors at organisations such as Depression Alliance,
Diabetes UK, the National Endometriosis Society, the British Liver
Trust, the ME Association, and the National Osteoporosis Society
found small improvements in self-efficacy, but no significant impacts
on health service use. The evaluators suggested that to reduce
service use, disease-specific information may need to be included
within the generic course structure or as a separate, but
complementary, course.45
To summarise what we already know about self-management
education:
− There is strong evidence that self-management education
improves self-efficacy.
− There is evidence that self-management education may improve
some clinical outcomes and reduce healthcare resource use and
expenditure, but these findings are not universal.
− There is no evidence that one type of self-management
education course is better than another.
W
WH
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TD
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ST
TH
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This review examined what types of personnel have facilitated selfmanagement education courses, and whether there is any evidence
that courses facilitated by some groups of people are more effective
than others. Although a great deal has been written about selfmanagement education, most researchers have not described the
course educators or compared different types of educators in any
detail.
44
45
Monninkhof E, van der Valk P, van der Palen J et al. Self-management education for
patients with chronic obstructive pulmonary disease: a systematic review. Thorax 2003;
58(5): 394-8.
Barlow JH, Wright C, Bancroft V, Turner A. Evaluation of the Chronic Disease SelfManagement Course. UK Department of Health and Long-term Medical Conditions
Alliance, 2003.
11
In addition to the reviews and studies described in the previous
section, we identified 21 studies describing self-management
educators explicitly. These included:
−
−
−
−
−
people with long-term conditions,
primary care nurses,
primary care teams,
hospital specialists,
and school teachers.
Only one systematic review and one additional early trial were
identified that explicitly compared self-management courses taught
by people with long-term conditions versus courses taught by
professionals.46,47 Both found that that peer-taught and professionaltaught courses had similar outcomes.
P
PE
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TH
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TIIO
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NS
S
A number of systematic reviews and randomised trials have focussed
on the effects of peer-led courses. The majority of studies and reviews
were cited in the section above. This section provides further details
of a small number of examples for illustrative purposes.
It is generally accepted that peer-led education can provide real
benefits for both participants and peer facilitators themselves. A
systematic review of 19 studies found that health education by lay
people improved access to care and promoted behaviour change.
Eight out of ten studies where lay people helped to manage
healthcare found improved access to care.48
In a study typical of its type, peer facilitated Chronic Disease Self
Management Programme sessions, each of two and a half hours
duration, were provided in community settings for groups of 15 to 20
people with heart disease, lung disease, stroke, or arthritis. Another
group received usual care (standard visits to health professionals
with no peer training). After two years, the self-management group
had reduced emergency department and outpatient visits and
improved self-efficacy compared to people receiving usual care.49
Programmes of this nature also appear to transfer well to people who
speak languages other than English. In the US, Spanish speakers with
heart disease, lung disease, or diabetes were randomised to a 6-week
community-based peer-led self management programme or usual
care. After four months, those who received self-management
education had improved health status, health behaviour, and selfefficacy, and fewer emergency department visits compared to those
who received usual care. These improvements were maintained after
one year.50
46
47
48
49
50
Lorig, K et al. A comparison of lay-taught and professional taught. arthritis selfmanagement courses J Rheum 1986; 13: 736-7.
Barlow, J, Wright, C, Sheasby J et al. Self-management approaches for people with
chronic conditions: a review. Patient Ed Counsel 2002; 48: 177-87.
Swider SM. Outcome effectiveness of community health workers: an integrative literature
review. Pub Health Nurs 2002; 19(1): 11-20.
Lorig KR, Ritter P, Stewart A et al. Chronic disease self-management program: 2 year
health status and health care utilization outcomes. Medical Care 2001; 39: 1217-23.
Lorig KR, Ritter PL, Gonzalez VM. Hispanic chronic disease self-management: a
randomized community-based outcome trial. Nurs Res 2003; 52(6): 361-9.
12
Similarly, a large randomised trial in China compared people with
hypertension, heart disease, chronic lung disease, arthritis, stroke, or
diabetes who received self-management education or no intervention.
The self-management initiative comprised education from a lay-led
course and a copy of a self-help book. Self-management education
improved participants' health behaviour, self-efficacy, and health
status and reduced the number of hospitalisations six months after
the course. The authors noted that Chinese lay tutors taught the
courses as successfully as professionals.51
The effects of self-management education may not be as marked for
children with long-term conditions. A randomised trial assessed peerled strategies for children aged 3 to 17 years with asthma in primary
care paediatric practices in the US. Interventions included teaching
physicians how to train peer educators, nurse-led visits, care
planning, and self-management support. Those receiving peer-led
education alone did not have significant clinical improvements
compared to children receiving usual care. However, those receiving
peer-led education plus nurse-led strategies had fewer days with
symptoms and reduced use of medication.52
A small number of observational studies have examined the effects of
self-management courses for peer tutors themselves. While these
studies are lower in the ‘evidence hierarchy’ they are summarised
here to illustrate an emerging trend in the literature. For instance, a
small study gained feedback from 11 volunteer peer tutors of a selfmanagement programme. Tutors said that being a lay-tutor was
enjoyable. Being a tutor also improved tutors' own self-management
behaviours.53
Talking Circles is a peer-led self-management programme for
American Indians with diabetes. An observational study of lay health
workers trained to present a diabetes curriculum and guide group
discussion found that facilitators valued the experience.54
Similarly, a small study in the UK assessed whether training to
become a lay tutor for an arthritis self-management course affected
21 tutors’ health status, use of self-management techniques, and
visits to general practitioners. Six months after training, tutors
reported small but significant improvements in arthritis self-efficacy
for pain, symptom management, mood, and communication with their
physician. They valued their status as lay leaders.55
51
52
53
54
55
Fu D, Fu H, McGowan P et al. Implementation and quantitative evaluation of chronic
disease self-management programme in Shanghai, China: randomized controlled trial.
Bull World Health Organ 2003; 81(3): 174-82.
Lozano P, Finkelstein JA, Carey VJ et al. A multisite randomized trial of the effects of
physician education and organizational change in chronic-asthma care: health outcomes
of the Pediatric Asthma Care Patient Outcomes Research Team II Study. Arch Pediatr
Adolesc Med 2004; 158(9): 875-83.
Barlow JH, Bancroft V, Turner AP. Volunteer, lay tutors' experiences of the Chronic
Disease Self-Management Course: being valued and adding value. Health Ed Res 2005;
20(2): 128-36.
Struthers R, Hodge FS, De Cora L, Geishirt-Cantrell B. The experience of native peer
facilitators in the campaign against type 2 diabetes. J Rural Health 2003; 19(2): 174-80.
Hainsworth J, Barlow J. Volunteers' experiences of becoming arthritis self-management
lay leaders: "It's almost as if I've stopped aging and started to get younger!" Arthritis
Rheum 2001; 45(4): 378-83.
13
As well as courses for people with long-term conditions, courses for
their carers are being trialled in England. Carers’ courses comprise a
two and a half hour session each week for six weeks led by local
Expert Patients Programme trainers and lay tutors who had personal
experience of caring for a person with a long-term condition. Twentynine carers took part in the pilot courses, and their feedback was
collated using surveys and interviews. The evaluation found that
carers thought the course helped them develop confidence and
motivation to use their own skills to take more effective control of their
lives.56
We did not identify any studies of the effects of courses for carers on
health status or resource use.
To summarise, there is good evidence that peer self-management
educators can improve self-efficacy and some health outcomes for
people with long-term conditions. Peer-led courses may also have
positive outcomes for peer tutors themselves, although there is a
paucity of evidence about this.
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S
Evidence about the effects of self-management education provided by
professionals is more sparse than that about peer-led education.
Studies of any design were eligible for inclusion given the paucity of
randomised trials identified.
We identified two randomised trials and one observational study
describing self-management education provided by primary care
nurses.
In the UK, 17 primary care practices compared a self-help package
facilitated by practice nurses or usual care by general practitioners
for people with mild to moderate anxiety and depression. The self-help
intervention consisted of three appointments: two 1 week apart and a
third 3 months later. People who received self-management education
had similar clinical outcomes and costs as the usual care group and
were more satisfied with their care.57
In Canada, a randomised trial of community-based nursing found that
self-help programmes can improve disability, resourcefulness, selfefficacy, behaviour, and life satisfaction among people with chronic
pain.58
56
57
58
Hare P, Newbronner E. Looking After Me: Evaluating a New Self-management Course for
Carers. A Report for the Expert Patients Programme and the Long-term Medical
Conditions Alliance, 2004.
Richards A, Barkham M, Cahill J et al. PHASE: a randomised, controlled trial of supervised
self-help cognitive behavioural therapy in primary care. Br J Gen Pract 2003; 53(495):
764-70.
LeFort SM. A test of Braden's Self-Help Model in adults with chronic pain. J Nursing
Scholarship 2000; 32(2): 153-60.
14
A small observational study in the US assessed a 12 week asthma
self-management course for eight and nine year olds taught by
primary nurses during school time. Children who took part had
significantly improved asthma management knowledge.59
Although these three studies suggest positive trends, there is
insufficient evidence to draw conclusions about the benefits of selfmanagement education provided by primary care nurses, or the
relative merits of nurse-led education compared to selfmanagement courses provided by others.
P
PR
RIIM
MA
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YC
CA
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RE
ET
TE
EA
AM
MS
S
We identified one randomised trial and three observational studies
about the effects of courses run by clearly described primary care
teams or by specialists in primary care settings. Other studies exist
about professional-led courses, but do not focus on the roles and
personnel involved.
All of the studies of courses for people with long-term conditions were
observational. For instance, a before and after study assessed an
asthma self-management programme in Switzerland. The intervention
included a booklet and a course taught by an interdisciplinary team of
pneumologists, primary care physicians, pharmacists, and specialist
nursing staff. Self-management
courses were associated with
improved quality of life and significant decreases in costs for asthma
treatment, hospitalisations, and lost workdays.60
Pharmacists have also been involved in self-management education,
especially in the US. However, there is limited information available
about the effects of such programmes. We identified one cohort study
of self-management education supported by pharmacy staff in a US
Army healthcare system. The initiative was associated with improved
knowledge, self-efficacy, opinion of the healthcare system, and
healthy behaviours. It also reduced clinic visits and visits to the
emergency department.61
A small cohort study in the US assessed the effects of selfmanagement education by a specialist. Six rural primary care
practices and 104 people with diabetes took part. For one year a
diabetes educator trained health professionals about diabetes
management and provided self-management education at primary
care clinics. Patients who received self-management education had
improved knowledge, empowerment, and clinical indicators
compared to those who did not receive self-management education.62
59
60
61
62
Horner SD. Using the Open Airways curriculum to improve self-care for third grade
children with asthma. J Sch Health 1998; 68(8): 329-33.
Tschopp JM, Frey JG, Pernet R et al. Bronchial asthma and self-management education:
implementation of Guidelines by an interdisciplinary programme in health network. Swiss
Med Wkly 2002;132(7-8): 92-7.
Steinweg KK, Killingsworth RE, Nannini RJ, Spayde J. The impact on a health care system
of a program to facilitate self-care. Mil Med 1998; 163(3): 139-44.
Siminerio LM, Piatt G, Zgibor JC. Implementing the chronic care model for improvements
in diabetes care and education in a rural primary care practice. Diabetes Educ 2005;
31(2): 225.
15
We identified one randomised trial about self-management education
delivered by a primary care team for the carers of people with longterm conditions. An asthma self-management programme for parents
of children with asthma aged under 5 years was delivered by general
practitioners, community nurses, asthma nurses, and doctors in child
health centres. Parents who participated in this course had more
knowledge, a more favourable attitude toward asthma, higher
competence in asthma self-management, and less doctor visits after
the programme.63
Although these four studies suggest positive trends, there is
insufficient evidence to draw conclusions about the benefits of selfmanagement education provided by primary care teams or
specialists, or the relative merits of courses led by primary care
teams compared to self-management courses provided by others.
H
HO
OS
SP
PIIT
TA
ALL S
ST
TA
AFFFF
Self-management courses have also been run by hospital staff. We
identified one randomised trial and one observational study that
clearly described the staff involved.
In Canada seven hospitals participated in a self-management
education programme for people with advanced chronic obstructive
pulmonary disease and at least one hospitalisation in the previous
year. Participants were randomly assigned to a self-management
programme or to usual care. The self-management initiative
comprised an education programme with weekly visits by trained
health professionals over a two month period plus monthly telephone
follow up. After one year, the self-management group had fewer
hospital admissions, emergency department visits, and unscheduled
physician visits compared with those receiving usual care.64
A small case control study in Thailand examined a multidisciplinary
hospital self-management training programme for people with
diabetes and their families. The education team included paediatric
endocrinologists, a dietician, a psychologist, nurses, scientists, and
volunteers. Compared to usual care, the multidisciplinary programme
reduced the average length of hospital admission, lowered
readmission rates, and improved glycaemic control.65
Although these two studies suggest positive trends, there is
insufficient evidence to draw conclusions about the benefits of selfmanagement education provided by hospital teams, or the relative
merits of courses led by hospital staff compared to selfmanagement courses provided by others.
63
64
65
Mesters I, Meertens R, Kok G, Parcel GS. Effectiveness of a multidisciplinary education
protocol in children with asthma (0-4 years) in primary health care. J Asthma 1994;
31(5): 347-59.
Bourbeau J, Julien M, Maltais F et al. Reduction of hospital utilization in patients with
chronic obstructive pulmonary disease: a disease-specific self-management intervention.
Arch Intern Med 2003 10;163(5): 585-91.
Likitmaskul S, Wekawanich J, Wongarn R et al. Intensive diabetes education program and
multidisciplinary team approach in management of newly diagnosed type 1 diabetes
mellitus: a greater patient benefit, experience at Siriraj Hospital. J Med Assoc Thai 2002;
85 Suppl 2: S488-95.
16
O
OT
TH
HE
ER
RE
ED
DU
UC
CA
AT
TO
OR
RS
S
Other studies have focused on the potential role of teachers or
educational staff in self-management education. For example, a
systematic review for a US Taskforce assessed self-management
education interventions for people with diabetes. The reviewers
concluded that there is insufficient evidence to assess the
effectiveness of self-management education at work or in summer
camps and inadequate evidence about the effect of educating coworkers and school staff about diabetes.66
A randomised trial in Australia assessed whether an asthma
education programme in schools would influence students’ and
teachers knowledge and attitudes towards asthma and the quality of
life of people with asthma. Thirty-two schools took part with 4161
students aged 13-14 years. Not all had asthma. Teachers delivered a
three-lesson package about asthma as part of the usual curriculum.
Students and teachers at schools that received asthma lessons had
improved knowledge of and tolerance towards asthma, selfmanagement perceptions, and overall quality of life compared to
those who did not receive asthma education.67
We identified one systematic review and one additional
randomised trial of self-management courses provided by other
educators. Evidence about the effectiveness of these personnel
remains inconclusive.
To summarise evidence about self-management educators:
− Most of the available evidence about self-management focuses
on courses provided by people with long-term conditions,
sometimes with the support of a health professional or
administrator. There is strong evidence that peers make good
self-management educators, and can improve people’s
perceptions and self-efficacy. Health may also improve in many
instances.
− There is limited evidence comparing different types of selfmanagement educators. The few studies that exist suggest that
well trained peers and professionals are equally effective.
− There is limited evidence about the effectiveness of
professionals in the role of self-management educators. Primary
care nurses, primary care teams of GPs, nurses and
pharmacists, disease specialists such as dieticians, teachers,
and teams of hospital staff have all provided self-management
education, seemingly to good effect.
− The philosophy, teaching methods, and content of courses may
be more important than the type of person facilitating, as long as
the tutor is well trained to deliver the course.
66
67
Norris SL, Nichols PJ, Caspersen CJ et al. Increasing diabetes self-management education
in community settings. A systematic review. Am J Prev Med 2002; 22 (4 Suppl): 39-66.
Henry RL, Gibson PG, Vimpani GV et al. Randomized controlled trial of a teacher-led
asthma education program. Pediatr Pulmonol 2004; 38(6): 434-42.
17
EXPANDING NURSING ROLES
While three quarters of people with long-term conditions merely need
some support to manage their conditions themselves, others require
more intensive disease management from health and social care
professionals. One of the key components of disease management
programmes involves expanding the roles of nurses.
This section describes:
−
some of the ways in which nursing roles
are being expanded,
−
general evidence about the effects of
expanding nursing roles,
−
and evidence about the effectiveness of
specialist nurses, primary care nurses
and hospital nurses in chronic care.
Disease
management
W
WH
HA
AT
TA
AR
RE
ET
TH
HE
ER
RO
OL
LE
ES
SO
OF
FN
NU
UR
RS
SE
ES
S??
Many initiatives to improve care for people with long-term conditions
are delivered by nurses. The most common strategies for expanding
the role of nurses include:
−
−
−
support from specialist nurses in primary or secondary care,
nurse-led clinics in primary or secondary care,
and nurse-led outpatient follow-up by primary or secondary care
nurses.
Many studies of nurse-led care focus on case management. These are
reported in another section of the review.
Some nurses specialise in helping people with a particular type of
condition, such as diabetes nurses or asthma nurses. These nurses
may substitute for general practitioners in routine appointments, run
clinics to help monitor and inform patients, or undertake outreach and
educational work to upskill other health and social care professionals.
Specialist nurses can be based in either primary or secondary care.
Often they span the boundaries of both. Sometimes these nurses
specialise in more than one disease type, and can also be known as
Advanced Practice Nurses.
Nurse-led clinics can be for single patients or for groups of people
with long-term conditions. They aim to provide regular reviews of
symptoms and to help people with self-management and support.
They can be run in hospitals, in GP clinics, or in community venues.
Follow-up after hospital admission can be done by hospital nurses or
those based within the community. This may involve discharge
planning prior to leaving hospital, regular telephone support, or home
visits.
18
Example of expanding the role of primary care nurses
Castlefields Health Centre is a GP practice that employed specialist
nurses to run clinics for people with heart disease and diabetes. The
programme was a mix of case management and specialist nurse-led
clinics.
The programme involved disease registers, recall for a check-up in a
nurse-led clinic using computer-driven protocols, and active follow-up
of people not receiving optimal treatment.
The clinic for people with heart disease was run by a nurse employed
especially to take on this role. The clinic for diabetes was run by a
nurse alongside a dietician and a podiatrist.
For heart disease, the main outcome was a reduction in heart attacks.
Over a five year period, the total number of heart attacks reduced by
more than 50% and the number of deaths from heart attacks reduced by
about two thirds. Clinical control of diabetes also improved.68
W
WH
HA
AT
TD
DO
OW
WE
EA
AL
LR
RE
EA
AD
DY
YK
KN
NO
OW
W??
Many studies have investigated the role of specialist nurses or
compared the roles of nurses and other professionals. A recent
review of five systematic reviews and 10 additional randomised trials
found inconsistent evidence about the effects of nurse-led strategies
for people with long-term conditions. There is some evidence that
nurse-led strategies usually have similar clinical and quality outcomes
to physician-led strategies, but this is not always the case. 69
Another systematic review found that nurse-led interventions for
people with long-term conditions tend to be most effective with people
who are not too elderly, or if the intervention is tailored towards older
people with specific health problems. Effectiveness depended on the
duration of follow-up, the number of follow-up visits, and the
personality and training of the nurse.70
68
69
70
Castlefields Health Centre: Chronic Disease Management, unpublished, 2004
Singh D. Transforming Chronic Care: Evidence About Improving Care for People with
Long-term Conditions. Birmingham: University of Birmingham Health Services
Management Centre, 2005.
Frich LM. Nursing interventions for patients with chronic conditions. J Adv Nurs 2003;
44(2): 137-53.
19
W
WH
HA
AT
TD
DO
OE
ES
ST
TH
HIIS
SR
RE
EV
VIIE
EW
WA
AD
DD
D??
While many other reviews and randomised trials have outlined
initiatives led by nurses, most do not do this in the context of
workforce development issues. Fifty-three studies of the effects of
different types of nurses are summarised below. Only studies which
detailed the exact role of nurses are included here, although many
other initiatives exist in which nurses deliver services.
S
SP
PE
EC
CIIA
ALLIIS
ST
TN
NU
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There is inconsistent evidence about the benefits of care by specialist
nurses, who focus on helping people with one or more long-term
conditions, compared to care by other types of professionals.
A Cochrane review compared specialist nurse care for people with
diabetes in primary and secondary care compared with usual care in
hospital or at GP clinics. After one year there was no difference
between groups in diabetes control, emergency hospital admissions,
or quality of life.71
In contrast, a review of advanced practice nursing in the United
States included seven randomised trials, some of which focused on
older people with long term medical conditions. The authors reported
that advanced practice nurses have consistently improved patient
outcomes and reduced healthcare costs.
An additional randomised trial in the US assessed the effect of
advanced practice gerontological nurses working with nursing home
staff to implement evidence-based protocols for 197 elderly people.
Not all had long term conditions. Compared to usual care, people
receiving support from advanced practice nurses had improved
clinical outcomes and less cognitive deterioration.72
There appear to be some differences in the effectiveness of specialist
nurses depending on the speciality of the nurse. Nurses who focus on
asthma generally have positive outcomes. For example, a trial of
specialist asthma nurses in 44 general practices in the UK found that
specialist nurses reduced unscheduled visits for asthma compared to
usual care. The nurses reviewed patients in nurse-led clinics and
provided educational outreach, guidelines, and ongoing clinical
support for general practitioners and practice nurses.73
71
72
73
Loveman E, Royle P, Waugh N. Specialist nurses in diabetes mellitus (Cochrane Review).
In The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons.
Ryden MB, Snyder M, Gross CR et al. Value-added outcomes: the use of advanced
practice nurses in long-term care facilities. Gerontologist 2000; 40(6): 654-62.
Griffiths C, Foster G, Barnes N, et al. Specialist nurse intervention to reduce unscheduled
asthma care in a deprived multiethnic area: the east London randomised controlled trial
for high risk asthma (ELECTRA). BMJ 2004; 328(7432): 144.
20
Another randomised trial with children in The Netherlands found that
specialist nurse-led outpatient management of childhood asthma was
clinically comparable to management by a paediatrician. Healthcare
costs and outpatient visits reduced with nurse-led care.74
Similarly, a before and after study in the US examined an asthma
outreach programme for young people aged between 1 and 17 years.
The programme involved a single outreach nurse working an average
of 8 hours per week at an annual cost of US$11,115. Participants
received one-to-one orientation visits from the nurse who instructed
them about asthma management, medications, triggers, and use of
inhalers and peak flow meters. An individualised care plan was
devised by the nurse, primary care paediatrician, and, when
appropriate, an allergist. The outreach nurse maintained personal or
telephone contact with the families on a regular basis. Emergency
department and hospital admissions reduced, resulting in
significantly reduced cost of care.75
Findings for people with diabetes are mixed. A trial in the US
evaluated telephone follow up by nurses for low income people with
diabetes. In addition to usual care, participants received telephone
follow-up by a diabetes nurse educator. Compared with people
receiving usual care, those receiving telephone follow-up reported
fewer symptoms of depression, greater self-efficacy, and fewer days
in bed because of illness.76
On the other hand, in Ireland, a diabetes service included a
community-based diabetes nurse specialist and structured
communication across primary and secondary care. The intervention
was associated with improved diabetes care delivery and
psychosocial outcomes, but no significant changes in clinical
outcomes.77
In the UK, a randomised trial found that inpatient specialist nurses in
diabetes can improve outcomes, care and cost.78
A case control study in The Netherlands examined transferring the
care of people with stable diabetes from doctors in outpatient clinics
to nurse specialists in general practice. Primary care nurse-led care
had similar clinical outcomes to hospital-based care.79
74
75
76
77
78
79
Kamps AW, Roorda RJ, Kimpen JL, et al. Impact of nurse-led outpatient management of
children with asthma on healthcare resource utilisation and costs. Eur Respir J 2004;
23(2): 304-9.
Greineder DK, Loane KC, Parks P. Reduction in resource utilization by an asthma outreach
program. Arch Pediatr Adolesc Med 1995; 149(4): 415-20.
Piette JD, Weinberger M, McPhee SJ. The effect of automated calls with telephone nurse
follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial.
Med Care 2000; 38(2): 218-30.
Smith S, Bury G, O'Leary M et al. The North Dublin randomized controlled trial of
structured diabetes shared care. Fam Pract 2004; 21(1): 39-45.
Davies M, Dixon S, Currie CJ, et al. Evaluation of a hospital diabetes specialist nursing
service: a randomized controlled trial. Diabetic Medicine 2001; 18: 301-7.
Vrijhoef HJ, Diederiks JP, Spreeuwenberg C, Wolffenbuttel BH. Substitution model with
central role for nurse specialist is justified in the care for stable type 2 diabetic
outpatients. J Adv Nurs 2001; 36(4): 546-55.
21
In Scotland, people hospitalised with heart failure were randomised to
receive care from a specialist nurse or usual care. The intervention
started before discharge and continued after people left hospital, with
home visits for up to one year. People who received support from a
specialist nurse were less likely to die or be readmitted to hospital
compared to the usual care group.80
Results are less clear-cut for people with arthritis. A randomised trial
assessed the cost-effectiveness of nurse specialist care, in-patient
team care, or day patient team care for people with rheumatoid
arthritis. Care from nurse specialists resulted in equivalent quality of
life and functional status, at lower cost.81 However, there were no
significant differences in medical treatment, clinical outcomes, or
hospitalisations at two-year follow-up. 82
In the UK, people aged 60 or over who lived in their own homes were
randomly assigned to usual care or a stroke support service from
specialist nurses, including home visits. While there were few
significant differences in clinical outcomes, most patients and
caregivers felt they had benefited from the specialist nurse's
visits.83,84
It is not possible to compare most of the studies above because the
exact interventions that specialist nurses have been involved in
vary greatly. For instance, some of the studies above focus on
telephone support, others on home visits, and others on targeted
follow up support. This variation in the initiatives provided by
specialist nurses makes it difficult to draw conclusions about the
effects of these nurses on patient satisfaction, clinical outcomes,
and healthcare service use.
We cannot be certain whether it is the intervention that makes a
difference or the fact that a specialist nurse is involved. For
instance, home visits by general practitioners, by health visitors, or
by peer supporters may have equal benefits to home visits by a
specialist nurse. The available evidence generally does not
differentiate between the specific tasks carried out by specialist
nurses and the role of ‘specialist nurse’ itself.
80
81
82
83
84
Blue L, Lang E, McMurray JJ et al. Randomised controlled trial of specialist nurse
intervention in heart failure. BMJ 2001; 323(7315): 715-8.
van den Hout WB, Tijhuis GJ, Hazes JM et al. Cost effectiveness and cost utility analysis
of multidisciplinary care in patients with rheumatoid arthritis: a randomised comparison
of clinical nurse specialist care, inpatient team care, and day patient team care. Ann
Rheumatic Dis 2003; 62(4): 308-15.
Tijhuis GJ, Zwinderman AH, Hazes JM et al. Two-year follow-up of a randomized
controlled trial of a clinical nurse specialist intervention, inpatient, and day patient team
care in rheumatoid arthritis. J Adv Nurs 2003; 41(1): 34-43.
Dowswell G, Lawler J, Young J et al. A qualitative study of specialist nurse support for
stroke patients and care-givers at home. Clin Rehabil 1997; 11(4): 293-301.
Forster A, Young J. Specialist nurse support for patients with stroke in the community: a
randomised controlled trial. BMJ 1996; 312(7047): 1642-6.
22
S
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CLLIIN
NIIC
CS
S
One common initiative provided by specialist nurses is nurse-led
clinics. In a number of European countries there has been a shift
towards using nurse-led clinics to manage long-term conditions in
primary care. A review of the literature suggested that nurse-led
clinics may provide better quality care compared to traditional
physician-led primary care.85 Research from Sweden, The
Netherlands, and the UK suggests that nurse-led clinics are effective
for managing chronic obstructive airways disease and asthma,86 heart
failure,87 diabetes,88 and people receiving anticoagulant therapy.89
For example, a systematic review of 18 randomised trials of heart
failure clinics relying, at least in part, on specially trained nurses
found that nurse-led clinics are associated with reduced hospital
readmissions and fewer days in hospital compared to usual care.90
There have been positive outcomes from nurse-led clinics in both
primary and secondary care. A large randomised trial in the UK
examined specialist nurse-led clinics for people with diabetes and
hypertension or hyperlipidemia who were receiving hospital-based
care. Nurses provided clinics for participants, with attendance every
4-6 weeks, until targets were achieved. They provided lifestyle advice
and drug adjustment according to local guidelines. Compared to
usual care, participants who attended nurse-led clinics were more
likely to achieve their clinical targets after one year and had lower
mortality rates.91
In Scotland, a large trial of nurse-led primary care clinics for people
with heart disease found that nurse-led clinics improved risk factors
and reduced deaths. The effects were sustained after four years.92
85
86
87
88
89
90
91
92
Vrijhoef HJ, Diederiks JP, Spreeuwenberg C. Effects on quality of care for patients with
NIDDM or COPD when the specialised nurse has a central role: a literature review. Patient
Educ Couns 2000; 41: 243-50.
Vrijhoef HJ, Diederiks JP, Wesseling GJ et al. Undiagnosed patients and patients at risk
for COPD in primary health care: early detection with the support of non-physicians. J
Clin Nurs 2003; 12: 366-73.
Stromberg A, Martensson J, Fridlund B et al. Nurse-led heart failure clinics improve
survival and self-care behaviour in patients with heart failure. Results from a prospective,
randomised trial. Eur Heart J 2003; 24: 1014-23.
Vrijhoef HJ, Diederiks JP, Spreeuwenberg C, Wolffenbuttel BH. Substitution model with
central role for nurse specialist is justified in the care for stable type 2 diabetic
outpatients. J Adv Nurs 2001; 36: 546-55.
Connor CA, Wright CC, Fegan CD. The safety and effectiveness of a nurse-led
anticoagulant service. J Adv Nurs 2002; 38: 407-15.
Gustafsson F, Arnold JM. Heart failure clinics and outpatient management: review of the
evidence and call for quality assurance. Eur Heart J 2004; 25(18): 1596-604.
New JP, Mason JM, Freemantle N et al. Specialist nurse-led intervention to treat and
control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled
trial. Diabetes Care 2003; 26(8): 2250-5.
Murchie P, Campbell NC, Ritchie LD et al. Secondary prevention clinics for coronary heart
disease: four year follow up of a randomised controlled trial in primary care. BMJ 2003;
326(7380): 84.
23
A smaller trial in the US compared nurse-led outpatient management
of childhood asthma versus follow-up by a paediatrician. After one
year, there were no significant differences between groups in
symptom-free days, health status, quality of life of patients, or quality
of life of caregivers. The authors concluded that following initial
assessment in a multidisciplinary clinic, childhood asthma can be
successfully managed by an asthma nurse in close cooperation with a
paediatrician.93
However, other studies have found less positive results. A Cochrane
review suggested that nurse-led clinics for chronic airways disease
may improve outcomes when the disease is moderate, but not when it
is severe94
In the UK, a randomised trial assessed the impact of providing a nurse
follow-up clinic in addition to the usual service provided by a
dermatology outpatient department for people with eczema or
psoriasis. One group received usual care. The other received an
additional session with a dermatology nurse specialist immediately
after their consultation with the dermatologist. People who took part
in the nurse specialist clinic had better knowledge then those who
received usual care, but there were no differences between groups in
quality of life.95
Another randomised trial in the UK found that school-based nurse-led
clinics for adolescents with asthma increased uptake of asthma
reviews, but did not improve clinical outcomes compared to usual GP
care.96
Similarly, a randomised trial in the US compared care processes and
outcomes of nurse practitioners versus primary care physicians for
adults with type 2 diabetes. Nurse practitioners documented the
provision of diabetes education and selected monitoring tests more
frequently than doctors, but these differences had no effect on
people’s health outcomes at six months.97
93
94
95
96
97
Kamps AW, Brand PL, Kimpen JL et al. Outpatient management of childhood asthma by
paediatrician or asthma nurse: randomised controlled study with one year follow up.
Thorax 2003; 58(11): 968-73.
Smith B, Appleton S, Adams R, Southcott A, Ruffin R. Home care by outreach nursing for
chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2001;
(3):CD000994.
Gradwell C, Thomas KS, English JS, Williams HC. A randomized controlled trial of nurse
follow-up clinics: do they help patients and do they free up consultants' time? Br J
Dermatol 2002;147(3): 513-7.
Salisbury C, Francis C, Rogers C et al. A randomised controlled trial of clinics in secondary
schools for adolescents with asthma. Br J Gen Pract 2002; 52(485): 988-96.
Lenz ER, Mundinger MO, Hopkins SC et al. Diabetes care processes and outcomes in
patients treated by nurse practitioners or physicians. Diabetes Educ 2002; 28(4): 590-8.
24
To summarise, while a great deal has been written about initiatives
run by specialist nurses, including nurse-led clinics, evidence of
the effectiveness of these approaches remains uncertain. Some
studies have found definite improvements associated with
specialist nurse-led strategies, whereas other have found less
benefits.
Nurse-led clinics themselves vary widely in type, function, and
duration. For instance, some of the studies summarised above
focus on a one-off nurse-led educational appointment, whereas
others examine weekly or monthly clinic visits. Some studies focus
on clinics in primary care. Others focus on hospital-based clinics.
And while some clinics are run by nurses alone, others include
nurses as part of a broader multidisciplinary team. All of these
differences make it difficult to draw conclusions about nurse-led
clinics, and whether it is the nurse role itself that is important, or
the use of regular follow up (by any type of staff).
However, the available evidence does suggest that nurses trained
to provide specialist care for people with a particular type of longterm condition can be involved in many beneficial initiatives,
including nurse-led clinics.
H
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There is also some evidence about the roles of nurses in hospital.
These are usually ‘general nurses,’ rather than nurses trained to
provide specialist services for people with a particular long-term
condition.
We identified four studies that explicitly compared the care provided
by hospital nurses and others. Due to the paucity of evidence, studies
of any design were eligible. Studies of follow-up by hospital nurses are
described in the next section.
Although most studies are of limited quality, research that compares
substituting nurses for doctors in hospital has found that nurses and
doctors often have similar process and clinical outcomes. For
example, in the US, people on general medical wards were
randomised to receive care from either nurse practitioners or medical
house staff. Not all participants had long-term conditions. Outcomes
at discharge and six weeks after discharge were similar between
groups, including length of stay, cost of care, complications,
mortality, patient assessments of care, quality of life, and symptom
severity.98
98
Pioro MH, Landefeld CS, Brennan PF et al. Outcomes-based trial of an inpatient nurse
practitioner service for general medical patients. J Eval Clin Pract 2001; 7(1): 21-33.
25
A retrospective study in the US compared the care provided by nurse
practitioners versus doctors for hospitalised older people. The
authors concluded that nurse practitioners in hospital provide
effective care, particularly for those who are older and sicker.
Readmission and mortality rates were similar between nurses and
physicians.99
A case control study in the US compared the care provided by
hospital nurse practitioners, physician assistants, and residents. Not
all participants had long-term conditions. Clinical outcomes did not
differ markedly for people treated by nurses versus those treated by
clinicians.100
Another case control study in the US focused on older people visiting
the emergency department, some of whom had long-term conditions.
A geriatric nurse identified medical, dental and social problems using
standardised assessments and made recommendations to the
patient, family, and attending emergency department physician.
Attempts were made to arrange appropriate follow up services.
Physicians compiled with six out of ten nurse suggestions and
patients and families complied with one third of nurse
recommendations. There were no significant differences in mortality
between nurse-facilitated care and usual care.101
Not a great deal has been written about the role of hospital nurses
in disease management initiatives for people with long-term
conditions. The available evidence suggests that in some instances
hospital nurses can successfully be substituted for doctors,
however.
FFO
OLLLLO
OW
W--U
UP
PB
BY
YH
HO
OS
SP
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TA
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NU
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S
As well as looking at the roles of nurses within hospitals, some
initiatives have focused on follow-up by hospital nurses after
discharge.
For instance, in the UK, adults who attended emergency departments
with asthma were randomised to usual care or three outpatient follow
up appointments with a hospital-based specialist asthma nurse, six
weeks apart. Following assessment of their asthma treatment, the
nurses advised participants how to recognise and manage
uncontrolled asthma and when to seek medical assistance.
Medication and inhalers were altered if necessary. Compared to usual
care, hospital-based specialist nurses reduced asthma morbidity by
improving self-management behaviour which lead to reduced
symptoms, improved lung function, less time off work, and fewer
consultations with other health professionals.102
99
Lambing AY, Adams DL, Fox DH, Divine G. Nurse practitioners' and physicians' care
activities and clinical outcomes with an inpatient geriatric population. J Am Acad Nurse
Pract 2004; 16(8): 343-52.
100 Rudy EB, Davidson LJ, Daly B et al. Care activities and outcomes of patients cared for by
acute care nurse practitioners, physician assistants, and resident physicians: a
comparison. Am J Crit Care 1998; 7(4): 267-81.
101 Miller DK, Lewis LM, Nork MJ, Morley JE. Controlled trial of a geriatric case-finding and
liaison service in an emergency department. J Am Geriatr Soc 1996; 44(5): 513-20.
102 Levy ML, Robb M, Allen J et al. A randomized controlled evaluation of specialist nurse
education following accident and emergency department attendance for acute asthma.
Respir Med 2000; 94(9): 900-8.
26
In Canada, people with heart failure were randomised to receive usual
care or nurse-led support with the transition from hospital to home.
Follow up care from nurses was associated with less emergency
department visits and improved quality of life.103
Another trial with people hospitalised for heart failure in Canada
assessed a support programme comprising education, selfmonitoring, educational aids, a telephone hotline, and nurse follow up
at two weeks, then monthly for six months after discharge. Compared
to usual care, the group receiving nurse follow up had fewer
emergency department visits and days in hospital, and reduced cost
of care. There was no difference in adherence to medication.104
A trial with elderly people with heart failure in Sweden found that
follow-up by nurses after hospital discharge was more effective for
optimising medication than follow-up in primary care clinics.
However, nurse follow-up did not affect quality of life or hospital
readmission rates.105
On the other hand, a trial in Hong Kong examined follow-up by
hospital nurses following emergency department visits. Participants
received two telephone calls from an emergency department nurse,
within 1-2 days and 3-5 days after visiting the emergency department.
Not all participants had long-term conditions. The authors found that
people receiving nurse follow-up were more likely to use the
emergency department again within 30 days. Nurse telephone followups might have sensitised participants to healthcare needs.106
Five randomised trials of follow-up by hospital nurses, often by
telephone, have found varying results. In some instances nurse
follow-up reduced healthcare resource use. In other instances it
increased service use.
103
104
105
106
Harrison MB, Browne GB, Roberts J et al. Quality of life of individuals with heart failure: a
randomized trial of the effectiveness of two models of hospital-to-home transition. Med
Care 2002; 40(4): 271-82.
Tsuyuki RT, Fradette M, Johnson JA et al. A multicenter disease management program for
hospitalized patients with heart failure. J Card Fail 2004; 10(6): 473-80.
Mejhert M, Kahan T, Persson H, Edner M. Limited long term effects of a management
programme for heart failure. Heart 2004; 90(9): 1010-5.
Wong FK, Chow S, Chang K et al. Effects of nurse follow-up on emergency room revisits:
a randomized controlled trial. Soc Sci Med 2004; 59(11): 2207-18.
27
P
PR
RIIM
MA
AR
RY
YP
PR
RA
AC
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NU
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S
There is evidence that nurses working in primary practice are well
regarded by people with long-term conditions and can deliver care as
effectively as doctors in many instances. We identified six studies that
compared primary care nurses with doctors or outlined the role of
primary care nurses in initiatives to improve chronic care. Studies of
patient follow-up by primary care nurses are described in the next
section.
A meta-analysis comparing nurse practitioners versus physicians in
primary care included 38 studies. Not all studies focused on people
with long-term conditions. In randomised trials, participants were
more likely to comply with treatment recommendations from nurse
practitioners compared to physicians. Nurse practitioners were
equivalent to physicians on most other aspects.107
Another, more recent, systematic review of 34 studies examined
whether nurse practitioners working in primary care can provide
equivalent care to doctors. Not all studies focused on people with
long-term conditions. Participants were more satisfied with care by a
nurse practitioner compared to care from a general practitioner.
Nurse practitioners had longer consultations and made more
investigations compared to doctors. There were no significant
differences in health status, prescriptions, return consultations, or
referrals. The authors concluded that increasing the availability of
nurse practitioners in primary care may lead to high levels of patient
satisfaction and high quality care.108
An additional randomised trial in the US compared the quality of
primary care delivered by nurse practitioners versus doctors for
people who had visited a hospital emergency department. Not all
participants had long-term conditions. There were no differences
between groups in initial satisfaction, health status, or health service
use at six months. People with hypertension who received care from a
nurse practitioner had lower blood pressure than those receiving GP
care. The authors concluded that in primary care where nurse
practitioners had the same authority, responsibilities, administrative
requirements, and patient population as physicians, patients'
outcomes were comparable.109,110,111
107
108
109
110
111
Brown SA, Grimes DE. A meta-analysis of nurse practitioners and nurse midwives in
primary care. Nurs Res 1995; 44(6): 332-9.
Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners
working in primary care can provide equivalent care to doctors. BMJ 2002; 324(7341):
819-23.
Mundinger MO, Kane RL, Lenz ER et al. Primary care outcomes in patients treated by
nurse practitioners or physicians: a randomized trial. JAMA 2000; 283(1): 59-68.
Lenz ER, Mundinger MO, Kane RL et al. Primary care outcomes in patients treated by
nurse practitioners or physicians: two-year follow-up. Med Care Res Rev 2004; 61(3):
332-51.
Lenz ER, Mundinger MO, Hopkins SC et al. Diabetes care processes and outcomes in
patients treated by nurse practitioners or physicians. Diabetes Educ 2002; 28(4): 590-8.
28
Similarly, a retrospective study in the US compared different types of
staff providing primary care for 41,209 people. Not all had long-term
conditions. Participants were more likely to be satisfied with their
interactions in visits with nurse practitioners or physician assistants
compared to visits to doctors. Adults with diabetes were more
satisfied with appointments provided by doctors rather than nurses.112
A review of practice nurse care for people with heart failure in
Australia found a paucity of information about potential roles for
practice nurses. The studies identified were largely descriptive, but
suggested that practice nurses can help facilitate multidisciplinary
interventions and are perceived positively by people with heart
failure.113
However, the impacts on general practice teams are uncertain. A trial
in The Netherlands examined adding nurse practitioners to primary
care teams. Nurses undertook specific tasks for people with chronic
obstructive pulmonary disease or asthma, dementia, and cancer
according to agreed guidelines. Adding nurse practitioners to general
practice teams did not reduce the workload of general
practitioners.114
Two large reviews, two additional randomised trials and two other
studies have described general roles of primary care nurses in
some detail. Most studies suggest that nurses can provide
equivalent care for people with long-term conditions as that
provided by general practitioners.
The ‘type’ of nurse differed in these studies, however. Some
studies included specialist nurses, focussed on people with one
disease type, working within primary care. Others focussed on
more ‘general nurses,’ trained to provide care to people with a
wide variety of health conditions.
112
113
114
Roblin DW, Becker ER, Adams EK et al. Patient satisfaction with primary care: does type
of practitioner matter? Med Care 2004; 42(6): 579-90.
Halcomb E, Davidson P, Daly J et al. Australian nurses in general practice based heart
failure management: implications for innovative collaborative practice. Eur J Cardiovasc
Nurs 2004; 3(2): 135-47.
Laurant MG, Hermens RP, Braspenning JC, Sibbald B, Grol RP. Impact of nurse
practitioners on workload of general practitioners: randomised controlled trial. BMJ 2004;
328(7445): 927.
29
FFO
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A key role for primary care nurses involves routinely following up
people with long-term conditions. We identified one review and two
additional randomised trials that detailed follow up roles of primary
care nurses.
A Cochrane systematic review of 41 studies of primary care,
outpatient, and community care for people with diabetes found that
nurses who regularly contact patients can improve diabetes
management.115
In an additional randomised trial in the US, nurses telephoned people
with diabetes in between visits to the doctor to monitor their health
status and provide education. The intervention was associated with
improved glycaemic control, but not quality of life or diabetes-related
symptoms.116
A randomised trial in the US compared nurse follow-up in primary
care with usual care for people with depression. Nurses provided
regularly scheduled follow-up for 24 months. Nurse follow-up was
associated with clinical benefits and decreased outpatient costs for
people with depression who complained of psychological
symptoms.117
A number of other studies of nurse follow-up exist. Some focus on
follow-up as part of a broader programme, such as a case
management initiative. Evidence about case management is
presented overleaf. Other studies about nurse follow-up were outlined
above in the section on specialist nurses.
To summarise, there is some evidence that routine follow-up by
primary care nurses may improve the quality of care and clinical
outcomes for people with long-term conditions, especially
diabetes.
115
116
117
Renders CM, Valk GD, Griffin S et al. Interventions to improve the management of
diabetes mellitus in primary care, outpatient and community settings (Cochrane Review).
In: The Cochrane Library, Issue 2, 2001. Oxford: Update Software.
Weinberger M, Kirkman MS, Samsa GP et al. A nurse-coordinated intervention for primary
care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control
and health-related quality of life. J Gen Int Med 1995; 10: 59-66.
Dickinson LM, Rost K, Nutting PA et al. RCT of a care manager intervention for major
depression in primary care: 2-year costs for patients with physical vs psychological
complaints. Ann Fam Med 2005; 3(1): 15-22.
30
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Nurses working in the community or based in primary care practices
may also visit people with long-term conditions at home. These visits
may include routine clinical monitoring, medication reviews, and
social support. Evidence about the value of home visits is generally
positive, but inconsistent.
For example, a systematic review examined nurse home visits for
people with long-term conditions. Nurse visits were associated with
improved patient satisfaction, good clinical outcomes, and cost
savings.118
In the UK, a trial assessed a nurse-led management plan for people
aged over 65 years discharged from an emergency department after
a fall. Within four weeks, the intervention group received a home
assessment by a nurse. This included assessments of medication,
blood pressure, cognition, visual acuity, hearing, balance, mobility,
feet and footwear, and education about safety in the home. After six
months, the group receiving a nurse home visit had better function
than those receiving usual care.119
In Denmark, people aged 75 or older discharged from hospital were
randomly assigned to usual care or a home visit from a district nurse
on the day after discharge and a home visit from their GP two weeks
later. Not all had long-term conditions. After one year, those receiving
home visits were less likely to be admitted to a nursing home and had
fewer days in institutions.120
Similarly, a randomised trial in the US focused on 75 people with long
term conditions with three or more admissions to hospital.
Participants were visited by a nurse within seven days of discharge,
and for a total of nine times over the next three months. Compared to
usual care, home visits by nurses reduced rehospitalisation rates.121
Another randomised trial with older people who had been hospitalised
and were at high risk for poor outcomes found that home visits by
nurses reduced readmissions and days in hospital. There were no
significant differences in post-discharge care visits, functional status,
depression, or patient satisfaction.122
118
119
120
121
122
Frich LM. Nursing interventions for patients with chronic conditions. J Adv Nurs 2003;
44(2): 137-53.
Lightbody E, Watkins C, Leathley M et al. Evaluation of a nurse-led falls prevention
programme versus usual care: a randomized controlled trial. Age Ageing 2002; 31(3):
203-10.
Hansen FR, Spedtsberg K, Schroll M. Follow-up home visits to elderly patients after
hospitalization. A randomized controlled study. [Article in Danish] Ugeskr Laeger 1994;
156(22): 3305-7, 3310-1.
Williams H, Blue B, Langlois PF. Do follow-up home visits by military nurses of chronically
ill medical patients reduce readmissions? Mil Med 1994; 159(2):141-4.
Naylor MD, Brooten D, Campbell R et al. Comprehensive discharge planning and home
follow-up of hospitalized elders: a randomized clinical trial. JAMA 1999; 281(7): 613-20.
31
In Australia, people with chronic obstructive pulmonary disease were
randomly assigned to usual care or home visits by a community nurse
at one and four weeks after discharge and preventive general
practitioner care. Those receiving care from community nurses were
more satisfied with their care. There were no effects on general
practitioner visits, admission to hospital, or overall functional
status.123
A cohort study assessed preventive nurse home visits for elderly
people in Germany. Not all had long-term conditions. Home visits
were made by nurses who received special training and used an
established curriculum. Nurses were able to identify problems that
were unknown to general practitioners, but no information was
available about clinical outcomes.124
However, a cost analysis in Korea found that nurse visits for lowincome older people with long-term conditions was more costeffective than outpatient visits or residential care.125
Findings from eight studies suggest that home visits from nurses
can improve clinical outcomes and resource use, although this is
not universal.
123
124
125
Hermiz O, Comino E, Marks G et al. Randomised controlled trial of home based care of
patients with chronic obstructive pulmonary disease. BMJ 2002; 325(7370): 938.
von Renteln-Kruse W, Anders J, Dapp U, Meier-Baumgartner HP. Preventative home visits
by a specially trained nurse for 60-year olds and elderly in Hamburg [Article in German].
Z Gerontol Geriatr 2003; 36(5): 378-91.
Lee TW. Economic evaluation of visiting nurse services for the low-income elderly with
long-term care needs. Taehan Kanho Hakhoe Chi 2004; 34(1): 191-201.
32
To summarise evidence about the roles of nurses in disease
management programmes for people with long-term conditions:
− There is evidence that specialist nurses or advanced primary
nurses, trained to provide care for people with one or more longterm conditions, can make a valuable contribution to disease
management programmes. Specialist nurses may be based in
either primary or secondary care, or span the bounds of both.
While there is some conflicting evidence, and the exact benefits
may be disease-specific, the overall trend is for specialist nurses
to provide equivalent care to clinicians at the same or reduced
cost.
− Clinics run by specialist nurses and attended regularly by
individuals or groups of people with long-term conditions are
generally associated with improved clinical outcomes.
− There is a small amount of evidence that nurses in hospital can
effectively substitute for hospital doctors in some instances.
− There is insufficient evidence about the effects of discharge
planning and follow up by hospital nurses. Some studies have
found improved clinical outcomes and reduced service use,
others have found no effect or detrimental effects from hospital
nurse follow up.
− There is evidence that primary care nurses can provide care of
an equal quality to general practitioners for most people with
long-term conditions, at lower cost.
− There is evidence that regular follow-up by primary care nurses
and home visiting can improve the quality of care and clinical
outcomes for people with long-term conditions.
− It is uncertain whether it is the intervention (clinics, follow up, or
home visits) or the staff role (nurses) that makes a difference.
33
MULTIDISCIPLINARY TEAMS
Another key component of disease management programmes
involves working in multidisciplinary teams.
This section describes:
−
the concept of multidisciplinary
working,
−
general evidence about the effects of
multidisciplinary teams,
−
and the staff who make up some of the
multidisciplinary teams where there is
good evidence of effectiveness.
Disease
management
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The quality of care for people with long-term conditions may depend
on the degree to which professional relationships are collaborative
and multidisciplinary.126 Multidisciplinary teams involve people from
different specialities working together, such as doctors and nurses or
dieticians and cardiovascular specialists.
Multidisciplinary teams can be made up of hospital staff alone,
primary care staff alone, a mixture of primary and secondary staff, or
a mixture of healthcare, social services, and the voluntary sector.
The exact tasks of multidisciplinary teams depend where they are
based, who they are caring for, and what types of professionals they
involve. A common aim of all multidisciplinary teams, however, is to
draw together the strengths of different professions in order to
provide effective, well rounded, and cost-efficient care for people with
long-term conditions. Evidence about whether this works in practice
has been varied.
126
Andreason LE, Coriat B, den Hertog F, Kaplinsky R (eds). Europe's next step:
organisational innovation, competition and employment. Essex: Frank Cass, 1995.
34
Example of multidisciplinary team work
Multidisciplinary teams include a wide range of professionals. To
illustrate variation in the types of staff in multidisciplinary teams, 66
disease management programmes in Canada were surveyed. Nine out of
ten multidisciplinary teams for people with long-term conditions
employ allied health professionals, such as physical, occupational and
pulmonary therapists and X-ray technicians. Three quarters of the
programmes employed nurses, and half had a physician on the team.
One quarter had pharmacists. The most effective collaborative models
of care included a shared definition of the problem; patient education
and support; a shared focus on specific problems; setting goals and
developing plans to reach them; support for self-management; close
monitoring of people with long-term conditions, and ensuring people
had access to primary care doctors or specialists when they had a
problem.127
There is some evidence that it is multiple interventions that make the
most difference and that changes to staff, to systems, or to education
alone might be relatively ineffective.128
W
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Much has been written about multidisciplinary team working.
Descriptions of the specific staff involved in teams are provided in the
next section.
There is inconsistent evidence about the effects of multidisciplinary
teams in both primary and secondary care. A review of 14 systematic
reviews plus 33 additional randomised trials found that the effects of
multidisciplinary teams on quality of life and clinical outcomes vary
considerably between studies, although most evidence suggests that
multidisciplinary teams can reduce the use of health services and
resources.129
Three systematic reviews of multidisciplinary teams in primary care
suggest that multidisciplinary primary care teams can have some
benefits, but do not necessarily lead to improved clinical outcomes in
people with chronic pain,130 heart failure,131 or dementia.132
127 Wong J, Gilbert J, Kilburn L. Seeking Program Sustainability in Chronic Disease
Management: The Ontario Experience. Ontario: The Change Foundation, 2004.
128 Bradley F, Wiles R, Kinmonth A-L, et al. Development and evaluation of complex
interventions in health services research: case study of the Southampton heart integrated
care project (SHIP). BMJ 1999; 318: 711 - 5.
129 Singh D. Transforming Chronic Care: Evidence About Improving Care for People with
Long-term Conditions. Birmingham: University of Birmingham Health Services
Management Centre, 2005.
130 Ospina M, Harstall C. Multidisciplinary pain programs for chronic pain: evidence from
systematic reviews. Edmonton: Alberta Heritage Foundation for Medical Research, 2003.
131 McAlister FA, Lawson FME, Teo KK et al. A systematic review of randomized trials of
disease management programs in heart failure. Am J Med 2001; 110: 378-84.
132 Opie J, Rosewarne R, Apos O, Connor DW. The efficacy of psychosocial approaches to
behaviour disorders in dementia: a systematic literature review. Aust NZ J
Psych 1999; 33(6): 789-99.
35
Multidisciplinary outpatient teams are often used to follow up people
who have been admitted to hospital with a long-term condition. A
systematic review in people with rheumatoid arthritis and randomised
trials in elderly people found that multidisciplinary outpatient teams
may improve functional outcomes more than usual care.133,134 Other
trials with elderly people and those with stroke found no effect on
health outcomes.135,136,137
A number of studies have assessed multidisciplinary hospital teams.
Trials in people with heart failure,138 arthritis,139 and elderly
people140,141 suggest that multidisciplinary hospital care can improve
physical functioning and reduce readmissions.
Evidence about the impact of integrating primary and secondary care
on the quality of care processes is inconsistent, but there appears to
be a trend towards improved quality of care and more effective use of
healthcare resources in integrated systems.142,143 Systematic reviews
of studies of people with depression144 and asthma145 suggest that
integrating primary and secondary care may be a key to the success
of some disease management programmes.
133
134
135
136
137
138
139
140
141
142
143
144
145
Vliet Vlieland TP, Hazes JM. Efficacy of multidisciplinary team care programs in
rheumatoid arthritis. Sem Arthritis Rheum 1997; 27(2): 110-22.
Fletcher AE, Price GM, Ng ES et al. Population-based multidimensional assessment of
older people in UK general practice: a cluster-randomised factorial trial. Lancet 2004;
364(9446): 1667-77.
Yeo G, Ingram L, Skurnick J, Crapo L. Effects of a geriatric clinic on functional health and
well-being of elders. J Gerontol 1987; 42(3): 252-8.
Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of
comprehensive geriatric assessment and multidisciplinary intervention after discharge of
elderly from the emergency department - the DEED II study. J Am Geriatr Soc 2004;
52(9): 1417-23.
Donnelly M, Power M, Russell M, Fullerton K. Randomized controlled trial of an early
discharge rehabilitation service: the Belfast Community Stroke Trial. Stroke 2004;
35(1):127-33.
McDonald K, Ledwidge M, Cahill J et al. Elimination of early rehospitalization in a
randomized, controlled trial of multidisciplinary care in a high-risk, elderly heart failure
population: the potential contributions of specialist care, clinical stability and optimal
angiotensin-converting enzyme inhibitor dose at discharge. Eur J Heart Fail 2001;
3(2):209-15.
Vliet Vlieland TP, Breedveld FC, Hazes JM. The two-year follow-up of a randomized
comparison of in-patient multidisciplinary team care and routine out-patient care for
active rheumatoid arthritis. Br J Rheumatol 1997; 36(1): 82-5.
Slaets JP, Kauffmann RH, Duivenvoorden HJ et al. A randomized trial of geriatric liaison
intervention in elderly medical inpatients. Psychosom Med 1997; 59(6): 585-91.
Evans RL, Connis RT, Hendricks RD, Haselkorn JK. Multidisciplinary rehabilitation versus
medical care: a meta-analysis. Soc Sci Med 1995; 40(12): 1699-1706.
Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente,
and the US Medicare programme: analysis of routine data. BMJ 2003; 327.
Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the
NHS with California's Kaiser Permanente. BMJ 2002; 324: 135-43.
Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions
to improve the management of depression in primary care: a systematic review. JAMA
2003; 289(23): 3145-51.
Eastwood AJ, Sheldon TA. Organisation of asthma care: what difference does it make? A
systematic review of the literature. Qual Health Care 1996; 5(3): 134-43.
36
There is some evidence that integrating primary care and hospital
care may improve people’s knowledge and satisfaction with care. An
assessment of 72 disease management programmes in the US found
that programmes were more effective if they had strong linkages to
primary care and included population-based approaches rather than
relying on referrals.146 People’s satisfaction was higher with
integrated approaches. On the other hand, a review of the effect of
integrating primary healthcare services on cost, outcomes, and user
acceptability found that in two out of four studies, integrated services
were associated with less positive outcomes than usual care.147
To summarise what we know about multidisciplinary teams:
− A great deal has been written about the benefits of
multidisciplinary teams compared to care from just one group of
professionals. However many studies do not describe in detail
the staff who make up the teams or their respective roles.
− There is evidence that multidisciplinary teams may reduce the
use of health services and costs for people with long-term
conditions. However the effects on clinical outcomes and
patient experience are less clear.
− There is evidence that teams of primary and secondary care
staff working together can improve patient outcomes, although
this varies according to the exact initiatives and the types of
long-term conditions people have.
W
WH
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ST
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HIIS
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VIIE
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DD
D??
This section examines in more detail the types of staff that have been
included in multidisciplinary teams and evidence of the effects of
these staff teams.
P
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We identified four studies that explicitly described teams made up of
nurses and doctors in primary care, and that described the roles of
each group in detail. Two of these studies focused on people with
diabetes.
146
147
Wagner EH, Davis C, Schaefer J et al. A survey of leading chronic disease management
programs: are they consistent with the literature? Manag Care Q 1999; 7(3): 56-66.
Briggs CJ, Capdegelle P, Garner P. Strategies for integrating primary health services in
middle- and low-income countries: effects on performance, costs and patient outcomes.
In The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons.
37
In the US, people with hypertension and diabetes received care from
their primary care doctor and a nurse or from their primary care
physician alone. After one year, people receiving combined GP and
nurse care had improved health and satisfaction compared to those
receiving GP care alone. Personnel costs were higher in the group
receiving joint care.148
In another US trial, children aged 3 to 17 years with asthma received
usual care; care from GPs who received training from peer GP tutors;
or care from GPs who received peer training plus nurse-led visits and
care planning. Collaborative care improved clinical outcomes.149
A randomised trial in Canada examined the effects of a nursephysician collaborative approach for people with diabetes. One group
received usual care from a GP. The other group received usual care
plus home visits from a nurse and consultation with an exercise
specialist, nutritionist, or both. After three months there were no
significant differences in health or quality of life, but participants said
that they felt more empowered.150
Finally, a retrospective study of elderly people in nursing homes
compared the care provided by teams of nurses and doctors versus
care by physicians alone. Not all participants had long-term
conditions. There was no difference between groups in emergency
department visits, emergency department costs, hospitalisations,
length of stay, or hospital costs. People receiving care from nurse
practitioner and physician teams were seen more often.151
To summarise, there is inconsistent evidence about the value of
primary care doctor and nurse collaboration. Some studies have
found improved clinical outcomes and satisfaction, others have
found increased costs and no significant improvement from usual
care.
148
149
150
151
Litaker D, Mion L, Planavsky L et al. Physician - nurse practitioner teams in chronic
disease management: the impact on costs, clinical effectiveness, and patients' perception
of care. J Interprof Care 2003; 17(3): 223-37.
Lozano P, Finkelstein JA, Carey VJ et al. A multisite randomized trial of the effects of
physician education and organizational change in chronic-asthma care: health outcomes
of the Pediatric Asthma Care Patient Outcomes Research Team II Study. Arch Pediatr
Adolesc Med 2004; 158(9): 875-83.
Taylor KI, Oberle KM, Crutcher RA, Norton PG. Promoting health in type 2 diabetes:
nurse-physician collaboration in primary care. Biol Res Nurs 2005; 6(3): 207-15.
Aigner MJ, Drew S, Phipps J. A comparative study of nursing home resident outcomes
between care provided by nurse practitioners/physicians versus physicians only. J Am
Med Dir Assoc 2004; 5(1): 16-23.
38
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Pharmacists are increasingly becoming involved in primary care
teams. In England, the Medicines Management Collaborative aims to
help people get the right medicines, in the right quantities, at the right
time. Sixty-six centres are currently piloting collaborative working
strategies such as community pharmacists working with GPs to
review medicines. Preliminary data suggest that these integrated
programmes increase reviews of patients’ medicines and ensure
patients receive help when they need it.152
This approach is supported by other evidence. For instance, a
Cochrane review examined the effect of expanding pharmacists'
roles. Twenty-five studies involving more than 16,000 patients were
included. Not all had long-term conditions. There was some evidence
that pharmacist involvement improved patient and physician
education.153
A number of trials from the US also suggest that incorporating
pharmacists into multidisciplinary teams can improve the quality of
care for people with long-term conditions. For instance, care from a
pharmacist as part of a multidisciplinary team for people with heart
failure reduced mortality. Pharmacist care included medication
evaluation, recommendations to the physician, patient education, and
follow-up telephone calls.154
Similarly, a trial in the US assessed the effect of including a clinical
pharmacist during all scheduled primary care visits for older people
taking five or more medications for long-term conditions. Over a one
year period, this integrated care programme reduced inappropriate
prescribing and adverse drug events.155
Two trials in the US assessed co-management of people with high
blood pressure by primary care physicians and clinical pharmacists.
The pharmacist provided patient education, treatment, and follow-up.
Compared to people receiving usual care, those who were comanaged had greater blood pressure reductions and less costly
care.156,157
Another US trial found that integrating pharmacy and primary care
helped to reduce inappropriate prescribing and improve medication
compliance in people at high-risk in a rural community.158
152
153
154
155
156
157
158
Chronic disease management and self-care. Department of Health, 2002.
Beney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on
health services utilisation, costs, and patient outcomes (Cochrane Review). In The
Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons.
Gattis WA, Hasselblad V, Whellan DJ, O'Connor CM. Reduction in heart failure events by
the addition of a clinical pharmacist to the heart failure management team: results of the
Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study.
Arch Intern Med 1999; 159(16): 1939-45.
Hanlon JT, Weinberger M, Samsa GP et al. A randomized, controlled trial of a clinical
pharmacist intervention to improve inappropriate prescribing in elderly outpatients with
polypharmacy. Am J Med 1996; 100(4): 428-37.
Borenstein JE, Graber G, Saltiel E et al. Physician-pharmacist comanagement of
hypertension: a randomized, comparative trial. Pharmacotherapy 2003; 23(2): 209-16.
Bogden PE, Abbott RD, Williamson P et al. Comparing standard care with a physician and
pharmacist team approach for uncontrolled hypertension. J Gen Int Med 1998; 13(11):
740-5.
Taylor CT, Byrd DC, Krueger K. Improving primary care in rural Alabama with a pharmacy
initiative. Am J Health Syst Pharm 2003; 60(11): 1123-9.
39
A similar randomised trial in Canada found that including pharmacists
in multidisciplinary care improved the quality of care and prescribing
for people with heart failure.159
Including pharmacists in care teams for elderly people discharged
from hospital with three or more medications also improved the
appropriateness of drug prescribing. Pharmacists consulted people
and their physicians at hospital discharge and for the following three
months. People who received care from a pharmacist were less likely
to have prescribing, dosage, or drug interaction problems.160
In contrast, a large randomised trial of structured pharmaceutical
care provided to elderly people in Europe found that while
participants rated community pharmacists positively, there were no
improvements in clinical outcomes, quality of life, or cost.161
Other trials also have conflicting findings. In the US, people with
depression received collaborative care by primary care and clinical
pharmacists or usual primary care alone. Pharmacists provided drug
therapy management and follow-up. After six months, those with a
pharmacist in their care team had better drug adherence and
satisfaction, but there were no significant differences between groups
in resource use or clinical improvement.162
A randomised trial with 48 family doctors in Canada examined the
effectiveness of pharmacists as consultants to primary care
physicians for elderly patients who were taking five or more
medications daily. Pharmacists conducted face-to-face medication
reviews with patients and gave written recommendations to their
physicians. After five months, there were no significant differences in
healthcare use or costs between groups.163
In the US, people with depression or dysthymia received pharmacist
consultations with routine primary care. A clinical pharmacist
undertook in-person and telephone consultations to help general
practitioners and patients with medication choices and dosing. There
were no significant improvements in medication use.164
Eight out of the 12 studies we identified suggested that integrated
pharmacy and primary care may have some benefits. Comanagement, individual medication reviews, and GP education all
appear to have some merits.
159
160
161
162
163
164
Bucci C, Jackevicius C, McFarlane K, Liu P. Pharmacist's contribution in a heart function
clinic: patient perception and medication appropriateness. Can J Cardiol 2003; 19(4):
391-6.
Lipton HL, Bero LA, Bird JA, McPhee SJ. The impact of clinical pharmacists' consultations
on physicians' geriatric drug prescribing. A randomized controlled trial. Med Care. 1992
Jul;30(7):646-58.
Bernsten C, Bjorkman I, Caramona M et al. Improving the well-being of elderly patients
via community pharmacy-based provision of pharmaceutical care: a multicentre study in
seven European countries. Drugs Aging 2001; 18(1): 63-77.
Finley PR, Rens HR, Pont JT et al. Impact of a collaborative care model on depression in a
primary care setting: a randomized controlled trial. Pharmacotherapy 2003; 23(9): 117585.
Sellors J, Kaczorowski J, Sellors C et al. A randomized controlled trial of a pharmacist
consultation program for family physicians and their elderly patients. CMAJ 2003; 169(1):
17-22.
Adler DA, Bungay KM, Wilson IB et al. The impact of a pharmacist intervention on 6month outcomes in depressed primary care patients. Gen Hosp Psych 2004; 26(3): 199209.
40
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As well as incorporating pharmacists into primary care teams, there
is some evidence to support broader teams of professionals in
primary care. We identified five studies that described in detail the
workings of other primary care teams, with negligible results.
Eight out of 11 trials in a systematic review of multidisciplinary team
follow-up and regular visits from a nurse, homecare aide, or volunteer
following discharge of the elderly from hospital found no effect of
multidisciplinary follow-up on self-perceived health.165
In the UK, general practices with a high proportion of South Asian
patients received Asian link workers and extra community diabetes
specialist nurse sessions or continued usual care. After one year,
people with diabetes who received additional care from link workers
and specialist nurses had small reductions in blood pressure and
cholesterol compared to usual care, but there were no differences in
glycaemic control.166
Another randomised trial in the UK compared a community-based
multi-professional stroke rehabilitation team versus usual care.
People who received care from a multidisciplinary community stroke
team were more satisfied with the emotional support they received,
but there were no differences in functional outcomes, mood, quality of
life, or knowledge of stroke. Nor were there any significant
differences in satisfaction with practical help or overall satisfaction.167
In Australia, high users of hospital services were randomly assigned
to usual care or care planning by a general practitioner plus
graduated case management depending on health status. There were
no significant differences between groups in quality of life or
mortality. Those receiving co-ordinated care had higher total
resource use, primarily due to extra costs for care planning, case
management, and administration.168
On a more positive note, a trial in Ireland found that multidisciplinary
care for people with heart failure was cost-effective compared to
usual care.169 Nurse-led education plus specialist dietician advice
significantly reduced hospital readmission compared with usual care
at 12 weeks.170
There is limited evidence about diverse primary care teams. The
evidence that does exist suggests that adding extra specialists to
primary care teams may not improve health or service use for
people with long-term conditions.
165
166
167
168
169
170
Cole MG. The impact of geriatric post-discharge services on mental state. Age
Ageing 2001; 30(5): 415-8.
O'Hare JP, Raymond NT, Mughal S et al. Evaluation of delivery of enhanced diabetes care
to patients of South Asian ethnicity: the United Kingdom Asian Diabetes Study (UKADS).
Diabet Med 2004; 21(12): 1357-65.
Lincoln NB, Walker MF, Dixon A, Knights P. Evaluation of a multi-professional community
stroke team: a randomized controlled trial. Clin Rehabil 2004; 18(1): 40-7.
Segal L, Dunt D, Day SE et al. Introducing co-ordinated care (1): a randomised trial
assessing client and cost outcomes. Health Policy 2004; 69(2): 201-13.
Ledwidge M, Barry M, Cahill J et al. Is multidisciplinary care of heart failure cost-beneficial
when combined with optimal medical care? Eur J Heart Fail 2003; 5(3): 381-9.
McDonald K, Ledwidge M, Cahill J et al. Heart failure management: multidisciplinary care
has intrinsic benefit above the optimization of medical care. J Card Fail 2002; 8: 142-8.
41
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Mental health specialists are increasingly working with primary care
providers to improve the co-ordination of care for people with longterm conditions such as depression and dementia. For instance, a
review of five randomised trials found that the effectiveness of
antidepressant treatments in adults may improve with collaborative
working between primary care clinicians and psychiatrists plus
intensive patient education, case management, telephone support,
and relapse prevention programmes.171
Similarly, a randomised trial of multidisciplinary care by a
psychiatrist, psychologist, and nurses in Australia found that
multidisciplinary care improved symptoms and behaviours more than
usual care in nursing home residents with advanced dementia.172
Another randomised trial assessed collaborative care for chronic
depression in the US. The programme comprised patient education,
consultation with a psychiatrist, shared care by a psychiatrist and GP,
and monitoring of follow-up visits and adherence to medication.
Collaborative care improved quality of care at moderate cost.173,174
Another large randomised trial in US primary care clinics evaluated
shared GP and specialist care for older people with depression.
Shared care included a depression care manager supervised by a
psychiatrist, a primary care manager who provided education and
case management, and brief psychotherapy interventions. Compared
to usual care, shared care reduced depressive symptoms and
severity, improved treatment adherence, increased satisfaction with
care, and improved perceived quality of life.175 The effects were
sustained after two and a half years.176 There were similar findings for
people with diabetes plus depression or dysthymia.177
An intervention for people aged 13 to 21 years with depression
included expert leader teams at each primary care practice, care
managers who supported primary care clinicians in evaluating and
managing depression, training for care managers in cognitivebehaviour therapy, and clinician education. After six months, those in
the collaborative care group reported fewer depressive symptoms,
better quality of life, and greater satisfaction with mental
healthcare.178
171
172
173
174
175
176
177
178
Clinical Evidence. London: BMJ Publishing Group, 2004.
Opie J, Doyle C, O'Connor DW. Challenging behaviours in nursing home residents with
dementia: a randomized controlled trial of multidisciplinary interventions. Int J Geriatr
Psychiatry 2002; 17(1):6-13.
Simon GE, Von Korff M, Ludman EJ et al. Cost-effectiveness of a program to prevent
depression relapse in primary care. Med Care 2002; 40(10): 941-50.
Simon GE, Katon WJ, VonKorff M et al. Cost-effectiveness of a collaborative care program
for primary care patients with persistent depression. Am J Psychiatry 2001; 158(10):
1638-44.
Unutzer J, Katon W, Callahan CM et al. Collaborative care management of late-life
depression in the primary care setting: a randomized controlled trial. JAMA 2002;
288(22): 2836-45.
Katon W, Russo J, Von Korff M et al. Long-term effects of a collaborative care intervention
in persistently depressed primary care patients. J Gen Intern Med 2002; 17(10): 741-8.
Katon WJ, Von Korff M, Lin EH et al. The Pathways Study: a randomized trial of
collaborative care in patients with diabetes and depression. Arch Gen Psych 2004;
61(10): 1042-9.
Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a quality improvement
intervention for adolescent depression in primary care clinics: a randomized controlled
trial. JAMA 2005; 293(3): 311-9.
42
On the other hand, a Cochrane review of 38 studies assessed the
effects of on-site mental health workers in primary care on the clinical
behaviour of primary care providers. There was no evidence that
adding mental health workers to primary care provider teams in
'replacement' models promoted a significant change in the behaviour
of primary care staff. 'Consultation-liaison' interventions where
primary care and mental health providers worked together may lead
to changes in prescribing, but these appeared to be short-term and
limited.179
Similarly, a randomised trial in the UK assessed Mental Health Link, a
quality improvement programme to facilitate communication between
the teams within general practice. People in the group receiving
integrated mental health and primary care had fewer psychiatric
relapses, but there were no differences in processes of care,
satisfaction, or general health. Staff in the quality improvement group
were more satisfied. The cost of the intervention was £63 per person
more than usual care.180
Another small trial in the UK compared usual primary care or
enhanced liaison with individual patients by key workers in general
practices for people referred for psychiatric care. Key workers aimed
to improve communication between primary and secondary care.
There was no difference in clinical outcomes between those receiving
usual care or key worker support.181
It appears that the effects of collaboration between primary care and
mental health services may depend on the severity of conditions. In
randomised trials in the US, people with depression received
collaborative care from general practitioners and consulting
psychiatrists. Psychiatrists provided brief psychoeducational
interventions, medications management, and patient education.
Among people with major depression, collaborative care was more
cost effective than usual care. Among people with minor depression,
collaborative care was more costly than usual care.182,183
Evidence from 10 studies suggests that collaborative care from
mental health specialists and primary care staff may have some
process and clinical benefits, at least in the short term. However
other studies have found no benefits.
179
180
181
182
183
Bower P, Sibbald B. On-site mental health workers in primary care: effects on
professional practice (Cochrane Review). In The Cochrane Library, Issue 2, 2004.
Chichester, UK: John Wiley & Sons.
Byng R, Jones R, Leese M et al. Exploratory cluster randomised controlled trial of shared
care development for long-term mental illness. Br J Gen Pract 2004; 54(501): 259-66.
Emmanuel JS, McGee A, Ukoumunne OC, Tyrer P. A randomised controlled trial of
enhanced key-worker liaison psychiatry in general practice. Soc Psychiatry Psychiatr
Epidemiol 2002; 37(6): 261-6.
Von Korff M, Katon W, Bush T et al. Treatment costs, cost offset, and cost-effectiveness
of collaborative management of depression. Psychosom Med 1998; 60(2): 143-9.
Katon W, Von Korff M, Lin E et al. Collaborative management to achieve treatment
guidelines. Impact on depression in primary care. JAMA 1995; 273(13): 1026-31.
43
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Evidence is also available about different staff working together in
hospital. We identified seven studies that detailed the exact personnel
working in multidisciplinary hospital teams.
A Cochrane review of interventions designed to improve collaboration
between hospital nurses and doctors included two trials. One trial
found that daily structured team ward rounds, in which nurses,
doctors and other professionals made care decisions jointly,
shortened the average length of hospital stay and reduced hospital
costs. There were no significant differences in mortality. The other
trial evaluated combined nurse-doctor ward rounds four times per
week. There were no significant differences between groups in length
of hospital stay or mortality. The reviewers concluded that increasing
collaboration between doctors and nurses in hospital improved
healthcare processes moderately, but had limited effects on
outcomes.184
On the other hand, a randomised trial in Thailand found that
physician-nurse collaboration and a multidisciplinary team approach
in hospital improved the quality of care.185
A number of studies have focussed on people hospitalised with heart
failure. For instance, in the US, people aged at least 70 years were
randomised to usual care or a multidisciplinary intervention. The
intervention involved education by a geriatric cardiac nurse,
medication review by a geriatric cardiologist, consultation with social
services to facilitate discharge planning, dietary teaching by a
dietician, and follow-up after discharge by a home care team. The
multidisciplinary strategy reduced readmissions and days in hospital,
particularly
among
those
at
moderate
risk
for
early
rehospitalisation.186 The overall cost of care was US$460 less per
person receiving multidisciplinary care compared with usual care.187
Another trial for people with heart failure compared a
multidisciplinary team at a day hospital with a cardiologist, nurses,
physiotherapist and individualised care plan versus usual care after
hospital discharge. At one year, the multidisciplinary programme
significantly reduced hospital readmissions and cardiac death
compared to usual care.188
184
185
186
187
188
Zwarenstein M, Bryant W. Interventions to promote collaboration between nurses and
doctors (Cochrane Review). In The Cochrane Library, Issue 2, 2004. Chichester, UK: John
Wiley & Sons.
Jitapunkul S, Nuchprayoon C, Aksaranugraha S et al. A controlled clinical trial of
multidisciplinary team approach in the general medical wards of Chulalongkorn Hospital. J
Med Assoc Thai 1995; 78(11): 618-23.
Rich MW, Vinson JM, Sperry JC et al. Prevention of readmission in elderly patients with
congestive heart failure: results of a prospective, randomized pilot study. J Gen Intern
Med 1993; 8(11): 585-90.
Rich MW, Beckham V, Wittenberg C et al. A multidisciplinary intervention to prevent the
readmission of elderly patients with congestive heart failure. N Engl J Med 1995;
333(18): 1190-5.
Capomolla S, Febo O, Ceresa M et al. Cost/utility ratio in chronic heart failure:
comparison between heart failure management program delivered by day-hospital and
usual care. J Am Coll Cardiol 2002; 40: 1259-66.
44
Similarly, people with chronically symptomatic irritable bowel
syndrome seen in a US hospital were randomly assigned to
collaborative care by both a gastroenterologist and a psychologist or
to medical treatment or psychological treatment alone. Collaborative
treatment consisted of three biweekly visits. The authors found that
short-term treatment with a gastroenterologist and psychologist
working together was more effective than medical treatment for
relieving symptoms in people with chronic irritable bowel
syndrome.189
There is also evidence about multidisciplinary hospital teams for
people who have suffered a stroke. A meta-analysis of 19 trials
examined the effects of organised inpatient (stroke unit) care
compared with conventional care. Specialist stroke unit interventions
were defined as either a ward or team exclusively managing stroke
(dedicated stroke unit) or a ward or team specialising in the
management of disabling illnesses, including stroke. Organised
inpatient care was characterised by coordinated multidisciplinary
rehabilitation, education programmes, and specialisation of medical
and nursing staff. Stroke unit care was associated with less days
spent in hospital, death, dependency, and institutionalisation.190
An additional randomised trial in the UK compared multidisciplinary
care in hospital for people with stroke. Participants received care in a
stroke unit with a multidisciplinary stroke team, on usual wards with
the support of a stroke team, or care at home. Stroke units were more
effective than a specialist stroke team or specialist home care in
reducing mortality, institutionalisation, and dependence after
stroke.191
There is good evidence that multidisciplinary teams in hospital or
following up people after hospital discharge can improve quality of
care and health incomes and reduce resource use.
However, most of these multidisciplinary interventions contain
other components such as increased follow up and medication
reviews. It is therefore unclear whether it is the multidisciplinary
nature of the team, or the additional contacts with staff, that
influence outcomes.
Similarly, it is uncertain which specific staff may be more or less
useful within multidisciplinary hospital teams. It is unclear if a team
of nurses and doctors would be more or less effective than a team
made up of nurses, doctors, and dieticians, for example.
189
Gerson CD, Gerson MJ. A collaborative health care model for the treatment of irritable
bowel syndrome. Clin Gastroenterol Hepatol 2003; 1(6): 446-52.
190 Stroke Unit Trialists' Collaboration. Collaborative systematic review of the randomised trials
of organised inpatient (stroke unit) care after stroke. BMJ 1997; 314(7088): 1151-9.
191 Kalra L, Evans A, Perez I et al. Alternative strategies for stroke care: a prospective
randomised controlled trial. Lancet 2000; 356(9233): 894-9.
45
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A great deal has been written about the effects of primary and
secondary care personnel working together. We identified 20 studies
that described in detail the personnel within such teams. Many other
research about joint primary and secondary care has been reported,
but generally these studies are not explicit about the types of staff
involved and their exact roles.
A number of studies have assessed shared care between hospital
teams and GPs. For instance, a systematic review of seven studies of
people with long-term conditions examined the effect of formal liaison
between GPs and specialist service providers. Formal liaison between
GPs and specialist services had little effect on most health outcomes,
although some physical and functional outcomes were improved,
particularly among people with chronic mental illness. Liaison
between GPs and specialist services generally improved patient
satisfaction and evidence-based behaviours among clinicians.192
Another meta-analysis of multidisciplinary follow-up programmes for
people with heart failure included 11 randomised trials of joint work
by family doctors, heart specialists, nurses, pharmacists, dieticians,
physical therapists, and social workers. Multidisciplinary follow-up
programmes were cost-effective and were associated with fewer
hospital admissions. There was no strong evidence that
multidisciplinary programmes improved quality of care or mortality.193
A meta-analysis of five randomised trials compared GP or hospital
care alone or shared GP and hospital care for people with diabetes.
Shared care programmes with a computerised prompting system for
GPs and patients had better attendance rates and better glycaemic
control compared to hospital care. However, shared care
programmes with less well developed support for GPs had adverse
outcomes for people with diabetes.194
An additional randomised trial with people with diabetes found that
shared GP and hospital care was as effective as hospital-based care.
The authors concluded that with adequate support from hospitalbased diabetes services, GPs are capable of providing appropriate
care for people with uncomplicated diabetes.195
A randomised trial in Scotland examined a computerised model of
shared care between general practitioners and hospital specialists
caring for people with high blood pressure. Shared care was more
cost-effective than either conventional care or follow-up in nurse-led
clinics.196
192
193
194
195
196
Mitchell G, Del Mar C, Francis D. Does primary medical practitioner involvement with a
specialist team improve patient outcomes? A systematic review. Br J Gen Pract 2002;
52(484): 934-9.
Ahmed A. Quality and outcomes of heart failure care in older adults: role of
multidisciplinary disease-management programs. J Am Geriatr Soc 2002; 50(9): 1590-3.
Griffin S. Diabetes care in general practice: meta-analysis of randomised control trials.
BMJ 1998; 317(7155): 390-6.
Hoskins PL, Fowler PM, Constantino M et al. Sharing the care of diabetic patients between
hospital and general practitioners: does it work? Diabet Med 1993; 10(1): 81-6.
McInnes GT, McGhee SM. Delivery of care for hypertension. J Hum Hypertens 1995; 9(6):
429-33.
46
On the other hand, another UK trial with people with diabetes found
no significant differences between integrated care and usual hospital
care. The integrated care group was seen in general practice every
three or four months and in the hospital clinic annually. GPs were
given written guidelines for integrated care. After two years there
were no significant differences between groups in metabolic control,
psychosocial status, knowledge, beliefs about control, satisfaction
with treatment, unscheduled admissions, or disruption of normal
activities. People receiving integrated care had more visits and
greater numbers of examinations at slightly lower cost.197
Collaboration between health professionals may help professionals
feel more confident about their decisions and care processes. A study
in Europe compared asthma care by GPs alone, care shared between
GPs and hospital clinics, and conventional specialist care. Integrated
care helped GPs care for people with asthma who they might
otherwise have referred for specialist review.198
Similarly, a trial in Australia assessed the impact of involving general
practitioners in post-discharge care of children with asthma. GPs
were telephoned when children from their practice were admitted.
Children and their GPs then received printed information detailing the
care received in hospital and recommended post-discharge care plus
educational booklets about asthma. The hospital made follow-up
appointments for children to visit their GPs. GPs in the intervention
group were more satisfied and felt they were more involved compared
to GPs receiving the usual level of communication, but there were no
differences between groups in the rate of follow-up appointments with
GPs.199
On the other hand, an observational study in Australia that collated
GP and hospital staff’s views about joint working found that there was
a lack of trust on both sides, and poor communication owing to
structural and perceptual problems. Hospital staff focused on
specialist care and outpatient follow-up and seemed largely unaware
of the role of GPs. They made no use of GPs' knowledge and often
wanted to do everything within the hospital. GPs often felt alienated
from the hospital system.200
197
198
199
200
Naji S, Cameron I, Russell I et al. Integrated care for diabetes: Clinical, psychosocial, and
economic evaluation. BMJ 1994; 308(6938): 1208-1212.
Osman LM, Abdalla MI, Russell IT et al. Integrated care for asthma: Matching care to the
patient. Euro Respiratory J 1996; 9(3): 444-8.
Marks MK, Hynson JL, Karabatsos G. Asthma: communication between hospital and
general practitioners. J Paediatr Child Health 1999; 35(3): 251-4.
Balla JI, Jamieson WE. Improving the continuity of care between general practitioners and
public hospitals. Med J Aust 1994; 161(11-12): 656-9.
47
Other studies have examined teams of many different personnel. In
New Zealand, people with chronic heart failure were randomly
assigned to usual care or integrated primary and secondary care.
Integrated care involved clinical review at a hospital-based heart
failure clinic early after discharge, individual and group education
sessions, a personal diary to record medication and body weight,
information booklets and regular clinical follow-up alternating
between the general practitioner and hospital clinic. Integrated care
improved quality of life and reduced total hospital admissions and
total bed days.201
Another study in New Zealand focused on people with moderate to
severe chronic obstructive pulmonary disease. The programme
included management guidelines, individual care plans, and
collaboration between patients, general practitioners, practice
nurses, hospital physicians and nurse specialists. People receiving
collaborative primary and secondary care had reduced
hospitalisations and days in hospital compared to usual care. The
authors concluded that key success factors were participation by
people with long-term conditions and information sharing among
healthcare providers.202
In Australia, people living in nursing homes were randomised to
receive usual care or multidisciplinary case conferences. Two
multidisciplinary case conferences involving the resident's general
practitioner, a geriatrician, a pharmacist and residential care staff
were held at the nursing home for each resident. The case conference
group had more appropriate medication, but participants’ behaviours
did not change. The authors concluded that outreach specialist
services can be delivered without direct patient contact.203
A study in Germany examined multidisciplinary rehabilitation for
people with chronic back pain. The multidisciplinary programme was
organised by a group of local healthcare providers in the community
(sports teachers, clinical psychologists, physiotherapists and
physicians) and included exercise therapy, physiotherapy, cognitivebehavioural therapy, muscle relaxation, and education. Compared to
usual care, the multidisciplinary group had improved physical and
mental health and fewer days off work. There were no differences in
reported pain or depression.204
201
202
203
204
Doughty RN, Wright SP, Pearl A et al. Randomized, controlled trial of integrated heart
failure management: The Auckland Heart Failure Management Study. Eur Heart J 2002;
23(2): 139-46.
Rea H, McAuley S, Stewart A et al. A chronic disease management programme can
reduce days in hospital for patients with chronic obstructive pulmonary disease. Intern
Med J 2004; 34(11): 608-14.
Crotty M, Halbert J, Rowett D et al. An outreach geriatric medication advisory service in
residential aged care: a randomised controlled trial of case conferencing. Age Ageing
2004; 33(6): 612-7.
Lang E, Liebig K, Kastner S et al. Multidisciplinary rehabilitation versus usual care for
chronic low back pain in the community: effects on quality of life. Spine J 2003; 3(4):
270-6.
48
A number of multidisciplinary studies have focused on people with
diabetes. In Israel, people with poorly controlled diabetes received
usual primary care or multidisciplinary primary and secondary care
from a diabetes team. After six months, people receiving
multidisciplinary care had improved clinical outcomes compared
usual care.205
A small randomised trial found that people with type 2 diabetes in
Canada favoured usual care plus home visits from a nurse and
consultations with exercise specialists and nutritionists over usual
care alone, saying they felt more empowered and self-efficacious with
the collaborative approach.206
A case series in the US evaluated a hospital-based diabetes
programme comprising self-management education, medical
management by a primary care provider supported by
recommendations from a diabetes advanced practice nurse,
nutritional counselling and quarterly follow-up appointments over one
year. The initiative was associated with more glycaemic control and
better adherence to screening and examinations.207
Similarly, an observational study in France examined collaboration by
general practitioners and diabetes specialists to develop guidelines
for people with diabetes. The authors concluded that if general
practitioners and specialists work together to develop protocols, this
can have positive benefits for healthcare processes and clinical
outcomes.208
However, a randomised trial of a combined primary-secondary care
education package found multidisciplinary teams did not improve
diabetes knowledge, awareness, or self-management for people from
South Asia living in the UK. Participants were invited to four or more
rotating visits per year by a diabetes specialist nurse, dietician, or
chiropodist working with general practice staff.209
Other studies have examined how specialists can best provide
services within primary care venues. A systematic review of nine
studies assessed clinics conducted by specialist medical
practitioners in primary care and rural hospital settings. Simple
'shifted outpatients' programmes improved access to specialist
services, but had no impact on health outcomes. Specialist outreach
as a component of interventions involving collaboration with primary
care or education was associated with improved health outcomes,
more efficient care, and less use of hospital services.210
205
206
207
208
209
210
Maislos M, Weisman D. Multidisciplinary approach to patients with poorly controlled type
2 diabetes mellitus: a prospective, randomized study. Acta Diabetol 2004; 41(2): 44-8.
Taylor KI, Oberle KM, Crutcher RA, Norton PG. Promoting health in type 2 diabetes:
nurse-physician collaboration in primary care. Biol Res Nurs 2005; 6(3): 207-15.
Grey N, Maljanian R, Staff I, Cruzmarino de Aponte M. Improving care of diabetic patients
through a collaborative care model. Conn Med 2002; 66(1): 7-11.
Varroud-Vial M, Mechaly P, Joannidis S et al. Cooperation between general practitioners
and diabetologists and clinical audit improve the management of type 2 diabetic patients.
Diabetes Metab 1999; 25(1): 55-63.
Vyas A, Haidery AZ, Wiles PG et al. A pilot randomized trial in primary care to investigate
and improve knowledge, awareness and self-management among South Asians with
diabetes in Manchester. Diabet Med 2003; 20(12): 1022-6.
Gruen RL, Weeramanthri TS, Knight SE, Bailie RS. Specialist outreach clinics in primary
care and rural hospital settings. Cochrane Database Syst Rev 2004; (1): CD003798.
49
Teams from primary and secondary care have also helped to provide
outpatient programmes. A randomised trial in the US examined a six
month multidisciplinary outpatient programme for people with chronic
heart failure at increased risk of hospital readmission. The
multidisciplinary team consisted of a cardiologist, a specialist heart
failure nurse, a telephone nurse coordinator and the patient's primary
care physician. Team members had contact with each patient
according to a prespecified schedule. The specialist nurse followed
an algorithm to adjust medications. Those receiving multidisciplinary
care had fewer hospital admissions and deaths and better quality of
life compared to people receiving usual care. The cost per participant
was similar between groups.211
There is evidence that collaboration between primary and
secondary care can improve processes and health outcomes for
people with long-term conditions. There is variable evidence about
collaboration between hospital teams and general practitioners,
perhaps because these initiatives often provide varying levels of
support and integration. There is more evidence for shared care
from teams made up of primary care personnel and specialists.
There is insufficient evidence about staff roles that have been used
to foster integration between primary and secondary care.
S
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In England, there is an increasing focus on a ‘whole system’ approach
to care, integrating health and social services. However, there is little
rigorous local evidence about the effectiveness of this approach. We
identified four studies that explicitly outlined the role of social care
staff in multidisciplinary teams.
A randomised trial in Italy evaluated integrated social and medical
care and case management for frail elderly people living in the
community. People receiving integrated social and medical care had
improved physical and cognitive function and were less likely to be
admitted to hospital or a nursing home compared to people receiving
usual care. Both groups used health services to the same extent, but
those receiving usual care had more home visits by general
practitioners. The estimated financial savings from integrated care
were US$1800 per person per year of follow up.212
Similarly a small trial of joint primary care treatment of childhood
asthma by a doctor, physiotherapist, psychologist, and social worker
found improved ventilatory capacity in children receiving integrated
care.213
211
212
213
Kasper EK, Gerstenblith G, Hefter G et al. A randomized trial of the efficacy of
multidisciplinary care in heart failure outpatients at high risk of hospital readmission. J
Am Coll Cardiol 2002; 39(3): 471-80.
Bernabei R, Landi F, Gambassi G et al. Randomised trial of impact of model of integrated
care and case management for older people living in the community. BMJ 1998;
316(7141): 1348-51.
Weingarten MA, Goldberg J, Teperberg Y et al. A pilot study of the multidisciplinary
management of childhood asthma in a family practice. J Asthma 1985; 22(5): 261-5.
50
An observational study in The Netherlands assessed a vocational
rehabilitation programme for people with chronic rheumatic
conditions. The programme was run by a multidisciplinary team
comprising a rheumatologist, a social worker, a physical and
occupational therapist, and a psychologist. Patients and practitioners
were highly satisfied with the programme, although they highlighted
the need for better communication between team members.214
On the other hand, US trials in people with heart failure assessed
multidisciplinary teams with pharmacists, dieticians, social workers,
heart failure nurses, and registered nurses. There were some positive
outcomes,215 but the multidisciplinary team did not reduce the use or
costs of healthcare. The intervention was most beneficial for people at
low risk or with less severe difficulties, but it increased the use of
healthcare and costs in people who were fully functional before
hospital admission.216
There is insufficient evidence about methods to integrate social
and medical care, and the effects of including social workers
within multidisciplinary teams. Although some studies of including
social workers in teams have favourable outcomes, there is no
evidence that including social workers was an essential
component of these programmes. This is not to say that integrated
social and medical teams are not useful, just that there is little
documented evidence of the effects.
W
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S
Another way to integrate care involves working with community
organisations or the voluntary sector. A number of authors have
suggested potential advantages with this approach or described their
attempts to use community centres, schools, churches, and voluntary
organisations (mostly for health promotion rather than chronic
care).217,218,219,220,221 However, few randomised trials or systematic
reviews have investigated the outcomes of partnerships with the
public and voluntary sectors.222
214
215
216
217
218
219
220
221
222
de Buck PD, Breedveld J, van der Giesen FJ, Vlieland TP. A multidisciplinary job retention
vocational rehabilitation programme for patients with chronic rheumatic diseases:
patients' and occupational physicians' satisfaction. Ann Rheum Dis 2004; 63(5): 562-8.
Riegel B, Thomason T, Carlson B et al. Implementation of a multidisciplinary disease
management program for heart failure patients. Congest Heart Fail 1999; 5(4): 164-170.
Riegel B, Carlson B, Glaser D, Hoagland P. Which patients with heart failure respond best
to multidisciplinary disease management? J Cardiac Failure 2000; 6(4): 290-9.
Lasater TM, Wells BL, Carleton RA, Elder JP. The role of churches in disease prevention
research studies. Public Health Rep 1986; 101(2): 125-31.
Lefebvre RC, Lasater TM, Assaf AR, Carleton RA. Pawtucket Heart Health Program: the
process of stimulating community change. Scand J Prim Health Care 1988; Sup 1: 31-7.
Demark-Wahnefried W, McClelland JW, Jackson B et al. Partnering with African American
churches to achieve better health: lessons learned during the Black Churches United for
Better Health 5 a day project. J Cancer Educ 2000; 15(3): 164-7.
Wells BL, DePue JD, Buehler CJ et al. Characteristics of volunteers who deliver health
education and promotion: a comparison with organization members and program
participants. Health Educ Q 1990; 17(1): 23-35.
Nader PR, Sallis JF, Rupp J et al. San Diego family health project: reaching families
through the schools. J Sch Health 1986; 56(6): 227-31.
Peterson J, Atwood JR, Yates B. Key elements for church-based health promotion
programs: outcome-based literature review. Public Health Nurs 2002; 19(6): 401-11.
51
Working in joint teams with voluntary groups is distinctive to providing
usual care in community venues. Providing care in the community has
been found to improve access to services, but not affect clinical
outcomes.223,224,225,226 However, a number of randomised trials in the
US suggest that church-based prevention programmes can improve
health outcomes.227,228
We found two studies that described in detail collaborative working
between health services and community or voluntary groups. A
randomised trial found that co-ordinating care between community
groups and healthcare providers can improve service use and
increase satisfaction. The US Alzheimer's Association integrated their
care consultation service with the services offered by a managed
care system for people with dementia and their caregivers, resulting
in improved access to services.229
Another US trial compared four strategies for people aged 65 and
older who were eligible for geriatric care management: information
via post; information via telephone; geriatric care management; or
geriatric care management with up to US$2000 worth of community
services including in-home support, transportation, respite, or
medical equipment. The authors reported significant barriers in
establishing contractual agreements between health services and
private and community agencies, locating sufficient community
agencies to provide needed services, and monitoring service
contracts.230
In addition to collaboration between health and community services, a
number of studies suggest that using community-based volunteers to
support people with long-term conditions can have some benefits. For
instance, a randomised trial in London found that volunteers
‘befriending’ women with chronic depression improved clinical
outcomes.231 Similarly, a randomised trial in Canada found that
community-based volunteers were just as effective as health
providers at reducing alcohol consumption among people with
chronic alcohol problems.232
223 Newcomer R, Yordi C, DuNah R et al. Effects of the Medicare Alzheimer's Disease
Demonstration on caregiver burden and depression. Health Serv Res 1999; 34(3): 66989.
224 Evans D, Mellins R, Lobach K et al. Improving care for minority children with asthma:
professional education in public health clinics. Pediatrics 1997; 99(2): 157-64.
225 Hanlon JT, Lindblad CI, Gray SL. Can clinical pharmacy services have a positive impact on
drug-related problems and health outcomes in community-based older adults? Am J
Geriatr Pharmacother 2004; 2(1): 3-13.
226 Leveille SG, Wagner EH, Davis C et al. Preventing disability and managing chronic illness
in frail older adults: a randomized trial of a community-based partnership with primary
care. J Am Geriatr Soc 1998; 46(10): 1191-8.
227 Yanek LR, Becker DM, Moy TF et al. Project Joy: faith based cardiovascular health
promotion for African American women. Public Health Rep 2001; 116 Suppl 1: 68-81.
228 Campbell MK, Motsinger BM, Ingram A et al. The North Carolina Black Churches United
for Better Health Project: intervention and process evaluation. Health Educ Behav 2000;
27(2): 241-53.
229 Bass DM, Clark PA, Looman WJ et al. The Cleveland Alzheimer's managed care
demonstration: outcomes after 12 months of implementation. Gerontologist 2003; 43(1):
73-85.
230 Enguidanos SM, Gibbs NE, Simmons WJ et al. Kaiser Permanente community partners
project: improving geriatric care management practices. J Am Geriatr Soc 2003; 51(5):
710-4.
231 Harris T, Brown GW, Robinson R. Befriending as an intervention for chronic depression
among women in an inner city. 1: Randomised controlled trial. Br J Psychiatry 1999; 174:
219-24.
232 Leigh G, Hodgins DC, Milne R, Gerrish R. Volunteer assistance in the treatment of chronic
alcoholism. Am J Drug Alcohol Abuse 1999; 25(3): 543-59.
52
There is insufficient evidence about joint working between health
services and voluntary groups or staff from community agencies.
This is not to say that integrated community and health teams are
not useful, just that there is little documented evidence of the
effects.
To summarise the evidence about multidisciplinary teams:
− Common multidisciplinary teams include teams of hospital staff
providing care in hospital or as outpatient services; primary
care teams made up of nurses and doctors, perhaps with the
addition of specialists such as dieticians; collaboration between
mental health and primary care services; and collaboration
between pharmacists and primary care teams.
− Teams that include social services staff, commonly social
workers, and community volunteers are also gaining popularity,
but there is a paucity of evidence about how these teams work
in practice.
− The most effective strategies for multidisciplinary team work
appear to involve staff working together to address the needs of
people holistically, rather than substituting one type of staff for
another.
− There is less evidence about the effectiveness of models where
different staff merely liaise with each other compared to models
where staff work together ‘hands on’ to provide care.
53
CASE MANAGERS
One of the most frequently discussed initiatives to improve care for
people with long-term conditions involves case management.
This section describes:
−
the concept of case management,
−
general evidence about the effects of
case management,
−
and the effects of different types of
case managers.
case
management
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RS
S??
Case management is a way of co-ordinating services for people with
long-term conditions or complex social and medical needs. There are
many different models of case management, but the broad principle is
to assign each person a 'case manager' or a small case management
team to:
−
−
−
−
−
assess the person’s needs,
develop a care plan,
arrange suitable care,
monitor the quality of care,
and maintain contact with the person and their family.
Commonly nurses working in primary care have been trained as case
managers. These may be specialist nurses, advanced nurse
practitioners, or district or practice nurses especially trained to take
on new roles. In England, Community Matrons will fulfil this role. In the
US, the Evercare and Pfizer models of care are both based around
case management by nurses.233
The Evercare model has been piloted in nine primary care trusts in
England. A full evaluation of outcomes by the National Primary Care
Research and Development Centre is due in 2006.234
In both the UK and US models, each case manager is usually
responsible for between 30 and 60 ‘cases.’ In some models once a
person with a long-term condition is added to a case manager’s
caseload they remain on it for life, even if this merely means an annual
telephone call. In other models, caseloads are more fluid, with people
receiving support while they are most in need and then being removed
from a case manager’s caseload when they no longer feel that they
need targeted support.
233 Matrix Consultancy. Learning distillation of Chronic Disease Management Programmes in
the UK. Modernisation Agency, 2004.
234 Implementing the Evercare Programme. Interim Report, unpublished, 2004, 2005.
54
Some case managers specialise in co-ordinating care for people with
a particular long-term condition, such as heart failure or diabetes.
These case managers are often specialist nurses. Other case
managers organise care for all older people with complex needs, or a
more general population group.
Some case managers offer care to everyone in a certain age group,
such as everyone over the age of 65 years. Others target only those at
highest risk of hospitalisation or complications.
Example of a case management programme
The Eldercare Project in Cornwall (EPIC) began in July 2004. EPIC is one
of several projects currently being run in Cornwall to reduce unplanned
hospitalisation and increase capacity in community services. The main
objective is to manage proactively the health of people aged over 75
who have a long-term condition and repeated unplanned hospital
admissions. EPIC have a team of 12 Advanced Primary Nurses, four
working in each primary care trust area, within selected GP practices.
The nurses aim to take on a maximum of 60 patients each.
Nurses assess people using structured tools. The assessment process
signposts the nurse to further interventions or referrals to other
services. The nurses work with people with long-term conditions to
enable them to identify the early signs of deterioration or exacerbation
of their chronic disease. The nurses liaise with general practitioners to
assess whether hospital admission is required and have a menu of
options to support the patient safely at home.
Evaluation is ongoing but in case studies individual patients report
benefits from the programme.235
W
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W??
A great deal has been written about case management for people with
long-term conditions, including descriptions of local initiatives.236 Yet
evidence of the effect of case management on clinical outcomes and
resource use remains inconsistent. This section outlines some of the
things we already know about the effects of case management. It
does not systematically review all available literature. Instead, the aim
is to highlight key trends.
235
236
Tovey R. Eldercare Project in Cornwall (EPIC). Cornwall and Isle of Scilly NHS Health and
Social Care Community, unpublished, 2004.
Improving management of long term conditions. A case management approach in Bristol
and South Gloucestershire, unpublished, 2004.
55
Some studies have found definite benefits from case management,
especially when delivered as part of a broader disease management
programme. For instance, a systematic review found that for people
with diabetes, case management may help to improve glycaemic
control, but evidence was drawn primarily from the US. The reviewers
suggested that case management is effective when delivered in
conjunction with broad disease management programmes and when
delivered with one or more additional educational, reminder, or
support interventions.237
Many hundreds of case management studies have been undertaken in
the field of mental health, including people with long-term conditions
such as dementia and chronic depression. A Cochrane review found
that case management in mental health meant more people remain in
contact with health services (one extra person remains in contact for
every 15 people who receive case management), but hospital
admission rates also increased. There was some evidence that case
management improved adherence to treatment, but the reviewers
found that case management did not generally improve clinical
outcomes, social functioning, or quality of life in people with mental
illness. Case management may also increase costs. The reviewers
concluded that case management is of questionable value in mental
health.238
In contrast, an older systematic review of case management in mental
health divided case management approaches into simple and more
complex types. Brokerage case management is the most simple. It
focuses on organising and coordinating services on behalf of the
patient. Clinical case management is more complex, and includes
programmes such as Assertive Community Treatment (ACT), the
Psychosocial Rehabilitation Model, and the Strengths Model. The
reviewers included 23 studies with almost four thousand participants.
They concluded that, when delivered as a direct service with high
staff / patient ratios, case management can have some impact on use
of services (including reduced hospital stay), satisfaction with
services, engagement with services, and social networks and
relationships.239
Another meta-analysis of 24 studies of case management for people
with severe and persistent mental illness found that overall, case
management interventions are effective. Seventy-five percent of
people who participated in these programmes did better than the
average person who had not been case managed. The reviewers
found no differences in the effectiveness of different types of case
management models in mental health.240
237
238
239
240
Norris SL, Nichols PJ, Caspersen CJ et al. The effectiveness of disease and case
management for people with diabetes. A systematic review. Am J Prev Med 2002; 22(4
Suppl): 15-38.
Marshall M, Gray A, Lockwood A, Green R. Case management for people with severe
mental disorders (Cochrane Review). In The Cochrane Library, Issue 2, 2004. Chichester,
UK: John Wiley & Sons.
Holloway F, Oliver N, Collins E, Carson J. Case management: a critical review of the
outcome literature. Euro Psychiatry 1995; 10(3): 113-28.
Gorey KM, Leslie DR, Morris T et al. Effectiveness of case management with severely and
persistently mentally ill people. Community Ment Health J 1998; 34(3): 241-50.
56
Another meta-analysis of 44 controlled trials assessed different types
of case management in mental health. Thirty-five studies compared
assertive community treatment or clinical case management with
usual care, and nine compared assertive community treatment with
clinical case management. Both types of case management were
more effective than usual care for reducing cost of care and family
burden and increasing family satisfaction with services. The total
number of admissions and the proportion of people hospitalised
reduced with assertive community treatment, but increased with
clinical case management. Assertive community treatment was more
effective than clinical case management for reducing days in
hospital.241
A cost-effectiveness analysis in the UK found that having a case
manager to coordinate services benefited older people with dementia
and their carers. Since there was no difference in the overall costs,
the authors concluded that intensive case management can be a costeffective intervention for people with dementia.242
Other studies have found that case management has no benefits over
usual care. For instance, a systematic review assessed 17 trials of
multidisciplinary teams, case management, and outreach or home
care combined or in isolation, compared with usual care for
particularly vulnerable populations including the chronically ill. The
reviewers found no benefits from case management in processes of
care, functioning, quality of life, or symptom control.243
Another systematic review found no strong evidence that case
management improved clinical outcomes for people with long-term
conditions, although there were benefits for patient satisfaction and
for people with certain types of diseases. The reviewers suggested
that while trials in Italy, Australia, and the UK have found benefits
from case management, trials in the US often find no positive effects
overall. The reviewers suggested that case management may work
best with older people and immediately following hospitalisation.
Differences in case management models make it difficult to compare
findings between trials.244
The Kings Fund reviewed 19 studies of case management for people
older than 65 years in Europe and North America, 14 of which were
randomised trials. The reviewers found inconsistent evidence about
the effectiveness of case management for preventing hospital
admission, reducing use of the emergency department, and
decreasing length of hospital stay. Only five out of the 19 included
studies found significant reductions in hospital admissions. 245
241
242
243
244
245
Ziguras SJ, Stuart GW. A meta-analysis of the effectiveness of mental health case
management over 20 years. Psychiatr Serv 2000; 51(11): 1410-21.
Challis D, von Abendorff R, Brown P et al. Care management, dementia care and
specialist mental health services: an evaluation. Int J Geriatric Psych 2002; 17(4): 31525.
Wadhwa S, Lavizzo-Mourey R. Do innovative models of health care delivery improve
quality of care for selected vulnerable populations: a systematic review. Joint Commission
J Quality Imp 1999; 25(8): 408-21.
Technology Assessment Unit, US Department of Veterans Affairs. Impact of case
management programs. Boston: US Department of Veterans Affairs, 2000.
Hutt R, Rosen R, McCauley J. Case Managing Long-Term Conditions. What Impact Does It
Have in the Treatment of Older People? London: Kings Fund, 2004.
57
Yet other studies suggest that case management may be beneficial
for specific groups, such as people at high risk of hospitalisation. For
instance, a trial in the US with peopled aged 7 to 16 years with
diabetes compared a case manager alone, case manager plus
psychoeducational modules, and standard diabetes care. Case
management plus education reduced the rate of adverse outcomes
compared with the other two groups. Case management plus
education was particularly beneficial for youth at ‘high risk.’246
In contrast, another randomised trial in the US assessing the effects
of case management among ‘high risk’ older people found no
evidence that a case managers reduced the use or cost of
healthcare.247
To summarise what we already know about case management:
− There is inconsistent evidence about the effects of case
management on clinical outcomes, satisfaction, and healthcare
resource use.
− A number of studies suggest that case management can have
benefits, especially for those who have the most complex needs,
however an equal number of studies have found limited benefits.
− The most comprehensive evidence is available for people with
mental health problems and diabetes, but evidence in these two
areas is also conflicting.
− There are different types of case management, including
general liaison models and more active targeted support. There
is no consistent evidence that one model of case management
works better than another.
W
WH
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TD
DO
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HIIS
SR
RE
EV
VIIE
EW
WA
AD
DD
D??
While many studies have outlined the advantages and limits of case
management or compared different types of case management, much
less has been written about the staff working as case managers. We
identified no high quality trials that explicitly compared the relative
merits of different types of staff as case managers, such as nurses
versus doctors or health visitors. However information is available
about a range of different staff who have taken on case management
roles.
246
247
Svoren BM, Butler D, Levine BS et al. Reducing acute adverse outcomes in youths with
type 1 diabetes: a randomized, controlled trial. Pediatrics 2003; 112(4): 914-22.
Boult C, Rassen J, Rassen A et al. The effect of case management on the costs of health
care for enrollees in Medicare Plus Choice plans: a randomized trial. J Am Geriatrics Soc
2000; 48(8): 996-1001.
58
We found 34 studies that described in some detail the types of staff in
post as case managers. These included:
−
−
−
−
−
−
primary care nurses,
other members of the primary care team,
hospital nurses,
other hospital staff,
psychiatric teams,
and people with long-term conditions.
P
PR
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EN
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UR
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SE
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S
The majority of studies that describe the case manager role in any
detail have focused on care by nurses in primary care settings. These
nurses may be based within GP practices or be roving community
nurses.
We found 14 studies that described in detail a primary care nurse’s
role in case management (and many other studies of nurse case
management that did not define roles in any depth). Evidence about
the effects of primary care nurse case managers varied considerably.
A number of studies found no benefits from primary nurse case
managers. For instance, in the United States people with diabetes
were assigned to a primary care nurse case manager or usual care
for one year. The nurse case manager followed written management
plans under the direction of a family physician and an endocrinologist.
All participants received ongoing care through their primary care
doctors. People receiving nurse case management in addition to
usual care had improved glycaemic control and self-reported health
status. Nurse case management was not associated with significant
changes in medication type or dose, body weight, blood pressure, or
lipids or with adverse events.248
Another similar trial of case management in two US centres included
people with poorly controlled diabetes. Nurse case managers worked
with patients and their primary care providers, monitoring and
coordinating care using telephone contacts, collaborative goal
setting, and treatment plans. The control group received educational
materials and usual care. Case management did not improve key
clinical outcomes for high-risk people with diabetes, although
participants were more satisfied with their diabetes care.249
A randomised trial with frail older people compared nurse case
management with usual care in Canada. There were no significant
differences in quality of life, satisfaction with care, functional status,
admission to hospital, or length of hospital stay. Case-managed older
adults were readmitted to the emergency department significantly
more often than the usual care group.250
248
249
250
Aubert RE, Herman WH, Waters J et al. Nurse case management to improve glycemic
control in diabetic patients in a health maintenance organization. A randomized,
controlled trial. Ann Intern Med 1998; 129(8): 605-12.
Krein SL, Klamerus ML, Vijan S et al. Case management for patients with poorly
controlled diabetes: a randomized trial. Am J Med 2004; 116(11): 732-9.
Gagnon AJ, Schein C, McVey L, Bergman H. Randomized controlled trial of nurse case
management of frail older people. J Am Geriatrics Soc 1999; 47(9): 1118-24.
59
In the US, low or moderate risk people with coronary artery disease
were randomly assigned to 12 weeks of a cardiac rehabilitation
programme, a physician supervised, nurse case management
programme, or a community-based cardiovascular risk reduction
program administered by exercise physiologists guided by a
computerised system based on national clinical guidelines. All
interventions improved cardiovascular risk factors, but primary care
nurse case management was no more effective than other
interventions.251
Some primary care nurses provide case management in hospital. In
Denmark, hospitalised people aged over 65 years were randomised to
usual care or a nurse-led intervention. A nurse visited the hospital
daily, liaised with the primary care sector, discussed discharge with
the patient and hospital staff, coordinated home care, and visited
participants at home after discharge. There were no differences
between groups in average length of stay in hospital, diagnostic
procedures, functional capacity, or mortality.252
Some case management programmes involve regular telephone
follow up alone. A US trial with people with heart failure assessed
nurse case management by telephone. The programme involved
structured telephone surveillance and coordination of care with
primary care physicians. Nurse case management by telephone had
no effect on hospital readmissions. The authors concluded that
telephone case management programmes may be less effective for
people at low risk than those at high risk.253
On the other hand, a number of studies have found clinical benefits
from primary care nurse case managers. A systematic review of
organisational and educational interventions to improve the
management of depression in primary care included 36 studies.
Compared to usual care, nurse case management in primary care
improved clinical outcomes.254
Similarly, a randomised trial with adults with heart disease found that
nurse case management was associated with improved clinical
outcomes such as lower cholesterol and enhanced diet and
exercise.255
251
252
253
254
255
Gordon NF, English CD, Contractor AS et al. Effectiveness of three models for
comprehensive cardiovascular disease risk reduction. Am J Cardiol 2002; 89(11): 1263-8.
Hendriksen C, Stromgard E, Sorensen KH. Cooperation concerning admission to and
discharge of elderly people from the hospital. 1. The coordinated contributions of home
care personnel. [Article in Danish] Ugeskr Laeger 1989; 151(24): 1531-4.
DeBusk RF, Miller NH, Parker KM et al. Care management for low-risk patients with heart
failure: a randomized, controlled trial. Ann Intern Med 2004; 141(8): 606-13.
Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions
to improve the management of depression in primary care: a systematic review. JAMA
2003; 289(23): 3145-51.
Allen JK, Blumenthal RS, Margolis S et al. Nurse case management of
hypercholesterolemia in patients with coronary heart disease: results of a randomized
clinical trial. Am Heart J 2002; 144(4): 678-86.
60
A randomised trial in the US included children with asthma aged
between 1 and 15 years. One group received asthma education. The
other group received the same education session and were followed
up by an asthma case management nurse for one year. The case
management group had less emergency department visits and
hospitalisations compared to children who did not receive case
management. Resource use reduced by between 57% and 75%
compared to usual care. Healthcare savings were between US$8 and
$12 for every dollar spent on the nurse's salary.256
In the US, the Community Nursing Organisation is a federal healthcare
model that provides ambulatory and outpatient services using nurse
case management. A primary nurse provider, working with elderly
people, their families, physicians, healthcare service providers, and
community organisations, assesses the need for care and arranges
for appropriate services. A one year observational study found that
nurse case management improved health status. Not all participants
had long-term conditions.257
Over a three year period, a nurse practitioner in the US evaluated the
health, functional, and social status of people aged 65 years and
above at an annual primary care office visit. The nurse provided case
management for people who were frail or in danger of becoming frail.
In the short-term, use of medical services increased in the case
management group, but health, function, health behaviours, and
patient satisfaction all improved compared to people who were not
case managed.258
The findings about case management by a primary care nurse are
inconsistent. Most studies suggest that primary nurse case
managers may have some impact on satisfaction and quality of
care, but do not necessarily improve clinical outcomes.
As with other interventions, case management by primary care
nurses varies greatly in frequency and method, as well as
effectiveness. It is uncertain whether the exact method of case
management influences outcomes, and whether primary care
nurse case management is more or less effective than case
management by any other group.
256
257
258
Greineder DK, Loane KC, Parks P. A randomized controlled trial of a pediatric asthma
outreach program. J Allergy Clin Immunol 1999; 103(3 Pt 1): 436-40.
Schraeder C, Shelton P, Britt T, Buttitta K. Case management in a capitated system: the
community nursing organization. J Case Manag 1996; 5(2): 58-64.
Fordyce M, Bardole D, Romer L et al. Senior Team Assessment and Referral Program-STAR. J Am Board Fam Pract 1997; 10(6): 398-406.
61
P
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In addition to nurses, other members of the primary care team have
provided case management. In some cases, nurses share the case
management role with other primary care professionals.
For instance, in the US, a randomised trial is underway to assess the
effectiveness of case management in primary care for African
Americans with diabetes. The two year trial is comparing telephone
follow-up by a trained lay health educator versus case management
by a team of nurses and community health workers. The nurse and
community health worker team prepares individual care plans
focussing on self-management, social issues, and screening and
management of diabetes-related complications. Participants visit
nurse case managers once yearly and community health workers visit
participants at home one to three times per year, with additional
follow-up contacts as needed. Written and verbal feedback is
provided to the participant's primary care physician. No information
about outcomes is available yet.259 However, a similar US trial
assessing the effect of nurse case management and community
health worker interventions on diabetes control for inner city African
Americans found that improvements in clinical outcomes were
greatest when nurse case managers and community health workers
worked together.260
In a three year study of co-ordinated care versus usual care, primary
care staff generated targets and sought appropriate care from
secondary care and allied health professionals for people with longterm conditions in rural areas of Australia. Care plans were reviewed
annually. Case management by the primary care team was associated
with significant improvements in health outcomes and reduced
hospital and medical expenditure for some people.261
Pharmacists have also been involved in case management. In a
randomised trial of case management for people with diabetes a
primary care pharmacist provided evaluation and modification of
pharmacotherapy, self-management diabetes education, and
reinforcement of screening processes through clinic visits and
telephone follow-up. People case managed by the pharmacist
achieved better diabetes control compared to people receiving usual
care.262
There is sparse evidence about the role of primary care
professionals, other than nurses, in case management. However,
the evidence that does exist suggests that further exploration of
the role of community health workers (health visitors) and
pharmacists may be warranted.
259
260
261
262
Gary TL, Batts-Turner M, Bone LR et al. A randomized controlled trial of the effects of
nurse case manager and community health worker team interventions in urban AfricanAmericans with type 2 diabetes. Control Clin Trials 2004; 25(1): 53-66.
Vetter MJ, Bristow L, Ahrens J. A model for home care clinician and home health aide
collaboration: diabetes care by nurse case managers and community health workers.
Home Healthc Nurse 2004; 22(9): 645-8.
Mills PD, Harvey PW. Beyond community-based diabetes management and the COAG
coordinated care trial. Aust J Rural Health 2003; 11(3):131-7.
Choe HM, Mitrovich S, Dubay D et al. Proactive case management of high-risk patients
with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. Am J
Manag Care 2005; 11(4): 253-60.
62
H
HO
OS
SP
PIIT
TA
ALL N
NU
UR
RS
SE
ES
S
Hospital nurses may act as case managers, especially in North
America. For example, in the US, people admitted to hospital were
assigned a nurse case manager to provide discharge planning and to
arrange for postdischarge outpatient follow-up. Not all participants
had long-term conditions. Those who received case management
discharge planning had improved continuity of care, but there was no
difference in readmissions or emergency department use.263
Another trial in the US compared nurse case management in a special
care hospital unit with traditional nursing care. Participants were
critically ill with long-term conditions. There were no significant
differences in length of stay, mortality, or complications. However, the
case management group had significant cost savings.264
In Canada, a nurse case manager at a tertiary care teaching hospital
coordinated an interdisciplinary treatment plan for people with
rheumatoid arthritis. Patients were discharged after completing
scheduled visits through ambulatory care services. This observational
study found improvements in patient perceptions and self efficacy.265
Another study in Canada compared nurse case management with
usual care for over 70 year olds discharged home from the
emergency department at risk for repeated hospital admissions. Case
management consisted of coordination and provision of healthcare
services by nurses, both in and out of hospital, for a 10-month period.
There were no significant differences in quality of life, satisfaction
with care, functional status, hospital admission, or length of hospital
stay. People receiving case management were readmitted to the
emergency department more often than usual care.266
Upon admission to hospital, people with chronic obstructive
pulmonary disease in Australia were randomly assigned to receive
case management from hospital nurses or usual care. People who
received case management reported significantly less anxiety one
month after hospital discharge, but this effect was not sustained.
There was little difference between groups in unplanned
readmissions, depression, symptoms, support, and subjective well
being. Patients and caregivers said that case management improved
access to resources and communication with staff. Nursing and
medical staff said that case management improved communication
between staff and enhanced patient care.267
Five studies of case management by hospital nurses found few
significant improvements to health status and service use. Hospital
case management programmes may involve less follow up than
community models.
263
264
265
266
267
Einstadter D, Cebul RD, Franta PR. Effect of a nurse case manager on postdischarge
follow-up. J Gen Intern Med 1996; 11(11): 684-8.
Rudy EB, Daly BJ, Douglas S et al. Patient outcomes for the chronically critically ill:
special care unit versus intensive care unit. Nurs Res 1995; 44(6): 324-31.
Barry J, McQuade C, Livingstone T. Using nurse case management to promote selfefficacy in individuals with rheumatoid arthritis. Rehabil Nurs 1998; 23(6): 300-4.
Gagnon AJ, Schein C, McVey L, Bergman H. Randomized controlled trial of nurse case
management of frail older people. J Am Geriatr Soc 1999; 47(9): 1118-24.
Egan E, Clavarino A, Burridge L et al. A randomized control trial of nursing-based case
management for patients with chronic obstructive pulmonary disease. Lippincotts Case
Manag 2002; 7(5): 170-9.
63
O
OT
TH
HE
ER
RH
HO
OS
SP
PIIT
TA
ALL S
ST
TA
AFFFF
We identified two studies of case management by other hospital staff.
Neither found significant clinical benefits from case management by
hospital teams.
A randomised trial of a multidisciplinary case management
programme for people with chronic renal insufficiency in the US
comprised consultations for primary care patients in a hospital
outpatient clinic staffed by two nephrologists, a renal nurse, a renal
dietician, and a social worker. There were no differences between
groups in renal function, health services use, medication use, or
mortality for up to five years.268
Similarly, a trial in Switzerland found that hospital-based case
management involving counselling by a clinician did not improve
cardiovascular risk factors or symptoms among people hospitalised
for coronary events.269
There is insufficient evidence about case management by hospital
staff other than nurses. The evidence that does exist is not
favourable.
P
PS
SY
YC
CH
HIIA
AT
TR
RIIC
CT
TE
EA
AM
MS
SO
OR
RS
SP
PE
EC
CIIA
ALLIIS
ST
TS
S
In addition to the systematic reviews of case management in mental
health described in a previous section, we identified four further
studies that described in detail case management by psychiatric
teams or specialists.
A randomised trial in Australia compared three interventions for
people living in nursing homes with dementia complicated by
depression or psychosis: psychogeriatric case management; general
practitioners with specialist psychogeriatric consultation; and
standard care. Participants in all three groups had improved clinical
outcomes. Case management by a psychogeriatric team was no more
effective than a specialist consulting with general practitioners or
than standard care.270
268
269
270
Harris LE, Luft FC, Rudy DW et al. Effects of multidisciplinary case management in
patients with chronic renal insufficiency. Am J Med 1998; 105(6): 464-71.
Nordmann A, Heilmbauer I, Walker T et al. A case-management program of medium
intensity does not improve cardiovascular risk factor control in coronary artery disease
patients: the Heartcare I trial. Am J Med 2001; 110(7): 543-50.
Brodaty H, Draper BM, Millar J et al. Randomized controlled trial of different models of
care for nursing home residents with dementia complicated by depression or psychosis. J
Clin Psychiatry 2003; 64(1): 63-72.
64
On the other hand, a trial in 18 primary care practices in the US
focused on people aged 60 years or older with major depression,
dysthymic disorder, or both. Participants received usual primary care
or up to one year of care from a depression case manager who was
supervised by a psychiatrist and a primary care expert. The case
manager offered education, care management, antidepressant
management, and brief psychotherapy support. After one year,
people receiving case management had reduced depression
symptoms, greater rates of treatment, more satisfaction with care,
less functional impairment, less sever depression, and better quality
of life compared to people receiving usual care.271
In New Zealand, a two year case control study assessed psychiatric
case management for people with chronic severe mental illness. One
group received psychiatric case management, using a model that
directly involved general practitioners. The other group received
standard outpatient care. People who received psychiatric case
management had fewer days in hospital and remained out of hospital
for longer than those receiving usual care.272
An observational study in Hong Kong compared case management by
community psychiatric nurses for people with chronic schizophrenia
with usual care by community teams. Over a five month period, nurse
case management was associated with improvements in
psychological and functional outcomes and patient satisfaction.273
In both systematic reviews and additional studies of case
management by mental health professionals, there are inconsistent
findings. While there are some trends towards positive outcomes
from case management by psychiatric specialists, these findings
are not universal.
P
PE
EE
ER
RC
CA
AS
SE
EM
MA
AN
NA
AG
GE
ER
RS
S
A new development is to involve peers as part of the team case
managing people with long-term conditions. Evidence about the
effects of peer initiatives is sparse, but initial findings have been
positive. For example, an analysis of eight published literature
reviews evaluated different models of case management. The
reviewers concluded that case management by paraprofessionals
and peers may improve health outcomes, but that further research is
required.274
271
272
273
274
Unutzer J, Katon W, Callahan CM et al. Collaborative care management of late-life
depression in the primary care setting: a randomized controlled trial. JAMA 2002;
288(22): 2836-45.
Wood K, Anderson J. The effect on hospital admissions of psychiatric case management
involving general practitioners: preliminary results. Aust N Z J Psychiatry 1995; 29(2):
223-9.
Chan S, Mackenzie A, Jacobs P. Cost-effectiveness analysis of case management versus a
routine community care organization for patients with chronic schizophrenia. Arch
Psychiatr Nurs 2000; 14(2): 98-104.
Bedell JR, Cohen NL, Sullivan A. Case management: the current best practices and the
next generation of innovation. Community Ment Health J 2000; 36(2): 179-94.
65
In the US, a trial compared case management for mentally disabled
people provided by peers or by professionals over a two year period.
There was no difference in overall clinical outcomes in peer versus
professional case management, but peer case management was
associated with greater improvements in quality of life, symptoms,
attitudes towards medication compliance, and satisfaction with
mental health treatment.275
Another US study examined whether employing people with mental
health problems as peer specialists in a case management
programme improves outcomes for people with serious mental illness.
Three case management initiatives were compared: teams of case
managers plus peer specialists; teams of case managers plus
assistants who did not have mental health problems; and case
managers alone. People receiving support from peer specialists had
better quality of life and self image, fewer major life problems, and
more frequent contact with their case managers.276
There is insufficient information to draw conclusions about using
peers in case management teams, but positive trends suggest that
further investigations in this area may be worthwhile.
To summarise the evidence about case managers:
−
The most common case managers are primary care nurses.
Hospital nurses have also acted as case mangers, usually with
less effect.
−
There is no evidence that one type of staff make better case
managers than others, because few studies have explicitly
compared different case management staff.
−
There is some evidence that primary and secondary care
nurses working as case managers can improve the quality of
care provided to people with long-term conditions, although
this does not always lead to improved health or reduced
service use.
−
Evidence about other case management staff is sparse.
−
People with long-term conditions may have a role in case
managing others with similar conditions.
275
276
Solomon P, Draine J, Delaney MA. The working alliance and consumer case management.
J Ment Health Adm 1995; 22(2): 126-34.
Felton CJ, Stastny P, Shern DL et al. Consumers as peer specialists on intensive case
management teams: impact on client outcomes. Psychiatr Serv 1995; 46(10): 1037-44.
66
IMPLICATIONS FOR
WORKFORCE DEVELOPMENT
This rapid review has assessed the key personnel providing innovative
care for people with long-term conditions in the areas of selfmanagement education, disease management with nurses and
multidisciplinary teams, and case management.
S
SU
UP
PP
PO
OR
RT
TE
ED
DS
SE
ELLFF--M
MA
AN
NA
AG
GE
EM
ME
EN
NT
T
The majority of people with long-term conditions require support only to
manage their own conditions on a day-to-day basis, rather than ongoing
specialist initiatives.
Self-management education courses are one way to help people with
long-term conditions care for themselves more effectively and to gain
confidence in doing so.
The review identified 21 systematic reviews, randomised trials, and
other studies describing the roles and personnel involved as selfmanagement educators in detail. The main types of personnel who have
worked as self-management educators are:
−
−
−
volunteers with long-term conditions,
primary care nurses,
and hospital nurses.
Teams of specialists have also facilitated some courses.
In England, the Expert Patients Programme is being rolled out across
the country. There is good evidence to support the benefits of this type
of peer-led programme on self-efficacy, but these programmes may not
always improve health outcomes.
There is no evidence to suggest that one type of personnel is any more
effective at providing self-management education than any other group.
While few studies have compared different types of self-educators
directly, those that do exist have found no significant differences
between courses led by peers or professionals. This suggests that the
current focus in England on peer educators is appropriate and that
there would be no benefit from redirecting additional resources to train
health or social care professionals as self-management educators.
67
D
DIIS
SE
EA
AS
SE
EM
MA
AN
NA
AG
GE
EM
ME
EN
NT
T
Disease management programmes target people at relatively high risk
of complications and health service use. Two key components of
disease management programmes are nurse-led care and
multidisciplinary teams.
The review identified 52 studies describing innovative roles for nurses
caring for people with long-term conditions or comparing the care
offered by nurses versus care from other professionals. The expansion
of nursing roles in chronic care has focussed on:
−
−
−
specialist nurses who target people with particular long-term
conditions,
nurse-led clinics in primary or secondary care,
and nurse-led follow up in primary or secondary care.
There is mixed evidence about the effectiveness of these approaches.
While many studies have found that nurse-led care improves people’s
satisfaction and reduces use of other health services, this has not
always been associated with improved health outcomes.
However, studies which compare the care provided by nurses with the
care provided by doctors or other professionals suggest that in most
instances nurses can substitute for doctors in primary care. Nurse-led
clinics and follow-up sessions, whether in person or by telephone, are
associated with improvements in care processes.
The findings support the government’s focus on nurse-led care, but
emphasise that nurses need adequate training, technological support,
and time in order to be most effective.
Nurses are often part of multidisciplinary teams. The review included
64 studies that described multidisciplinary teams to help people with
long-term conditions and outlined the exact staff within these teams.
Teams of staff working together have been drawn from:
−
−
−
−
−
−
within primary care,
within hospital,
within mental health and primary care,
within pharmacy and primary care,
spanning primary and secondary care,
and spanning social care and health services.
There is evidence that nurses and doctors working together in primary
and in secondary care can improve care processes and health
outcomes. There is also emerging evidence about the benefits of
including pharmacists in primary care teams, although most of this is
drawn from the United States.
There is less consistent evidence about the benefits of mental health
services working collaboratively with primary care. Nor is there much
evidence about the role of social services staff within collaborative
teams or ways that personnel from voluntary organisations and
community agencies have been involved.
68
The most promising initiatives appear to involve co-ordination,
communication, and joint working between primary and secondary
care. The review did not identify any high quality evidence about staff
roles that may help to interface between primary and secondary care or
joint working strategies between health and social care. However,
teams that had staff drawn from hospitals, from primary care, and from
the social sector often had positive effects on patient satisfaction,
health outcomes, and service use. Case managers are the main staff
role that have been used to facilitate co-ordination between primary
and secondary care.
C
CA
AS
SE
EM
MA
AN
NA
AG
GE
EM
ME
EN
NT
T
Case management involves co-ordination of care and regular follow-up
of people with highly complex needs. The review identified 34 studies
that described different staff who have taken on the role of case
managers. A large number of other studies described and evaluated
case management programmes but did not make clear the exact staff
taking on the case manager role.
Personnel who have taken on the role of case managers commonly
include:
−
−
−
primary care nurses,
hospital nurses,
and mental health workers.
Other teams in hospital, in primary care, and in pharmacy have been
involved in case management, but are less common. A new area of
study involves peer case managers.
There is inconsistent evidence about the effects of case management.
Some studies have found no benefits from case management. Others
have found significant improvements in care co-ordination and health
service resource use. There is no evidence that one type of case
management is consistently better than another.
The review identified no study that explicitly compared different types
of case managers. However, comparing the outcomes of studies
focussed on different personnel suggests that there are few significant
differences between the case management provided by nurses,
specialists, or pharmacists. Instead, critical success factors appear to
be effective communication systems, effective monitoring and recall
systems, organisational culture, and realistic caseloads.
To some extent the findings support the training of more Community
Matrons to work as case managers in England. However, the caveat is
that in order to be effective, case managers must be part of an
integrated system so significant investment in supporting staff roles,
technology systems, and changing organisational culture will also be
required if Community Matrons are to have a positive impact.
The findings of the review do not support investing in case managers
instead of other staff.
69
S
SU
UM
MM
MA
AR
RY
Y
When interpreting the findings of the review, it is important to bear in
mind that almost all of the studies involved complex interventions. In
very few instances were different personnel the only thing compared. It
is also important to emphasise that the context in which staff changes
take place has an impact on the outcomes. The lack of comparative
evidence available does not mean that there are no differences
between various types of professionals.
Bearing these caveats in mind, this rapid review suggests that:
−
Nurses have a central role to play in initiatives to improve care for
people with long-term conditions, whether in primary or secondary
care, as case managers, or as specialist nurses. The available
evidence suggests that in most instances nurses provide care that
is at least as effective as the care provided by doctors, and often
people are more satisfied with the care provided by nurses. This
suggests that the current focus in England on providing targeted
nurse-led support is justified.
−
Involving people with long-term conditions as part of the team,
either as peer educators or as peer case managers, may have
significant benefits. It may be desirable to investigate whether there
is any scope to involve peers in case management roles in the UK.
−
Case managers aim to co-ordinate services and to provide an
interface between primary and secondary care, and between health
and social services. There is little evidence about the extent to
which case managers, often nurses based in primary care, have
achieved this interface. Nor is the evidence about the benefits of
case management unequivocal. This suggests that case
management should be invested in as one component of a broader
disease management strategy.
−
There is little evidence to suggest that one type of staff is any better
than another type for delivering routine care for people with longterm conditions. Upskilling a wide variety of staff such as
volunteers, nurses, health visitors, social workers, and mental
health workers may be a feasible way of expanding the chronic care
workforce. However few studies have explicitly compared the
merits of these personnel.
−
As there is little evidence to recommend one professional group
over another in most situations, people developing new services for
and with people with long-term conditions could focus on identifying
particular needs and service gaps; outlining the competencies
required to meet these needs; and then considering the best people
to meet these needs (either from a new workforce or from the
current workforce with further training). Solely ‘upskilling’ current
staff is unlikely to meet the complex needs of people with long-term
conditions.
70