Case Management in the Valencian Community

Why was this example implemented?

In Spain, case management has been introduced mainly to reduce the high number of older patients who end up in hospitals due to the universalistic character (free of charge) of the Spanish national health system, although they would often be served more appropriately in other types of facilities or services (Garcés, 2000). 

The sustainable socio-health model conceives the convergence of social services and the health care system as a holistic model of care for people with LTC needs. Within this model, case management has been identified as an effective methodology and an appropriate strategy to promote the integration of services.

Based on this rationale, a specific case management programme was tested in 2004 in the Valencian Autonomous Region (Spain). The aim was to assess the effect of this specific case management programme in primary care with respect to the use and uptake of social and health care resources. 

Description

In 2004, the Ministry of Health estimated about 65,000 people above the age of 65 needing health and social care at home in the Valencian Community (Generalitat Valenciana 2004). With this target group in mind, the project consisted in setting up a pilot case management unit in two primary care centres in the town of Burjassot (Valencian Autonomous Region, Spain). Both public and private health and social care services participated in the project between 2004 and 2005 with 152 patients who had been divided into an intervention group (n=101) and a control group (n=51).

The direct work with the users participating in the project was carried out by a multidisciplinary team comprising a physician, a nurse and a social worker who were all motivated by the topic of the research and voluntarily engaged and trained for the purpose. All study protocols were approved by the Valencian Regional Government Ethics Committee of Health.

Patients potentially eligible to be included in the study were first detected by a physician, a nurse or a social worker of the primary care centres of Burjassot and then referred to the case management team. At this point, the case management team decided if the case would be included based on their assessment. If the patient obtained the values previously defined, s/he was included in the research and randomly assigned either to the control group or to the intervention group. Patients in the control group continued to use the same resources they had used hitherto, while new care pathways were designed for each patient in the intervention group. This included the following resources:

• Health care: primary care centre; specialised care centre; one home hospitalisation unit (at the public hospital Arnau de Vilanova in Valencia); one palliative care unit at the Dr. Moliner Long-Term Care Public Hospital in Valencia; one Public Mental Health unit in Valencia; ambulance service (health care adapted transport), non-pharmaceutical complementary benefits;
• Social care: two long-term and ten short-term places in the ‘Velluters’ nursing home for older people (Valencia); six places at the Day Centre for older people in Burjassot; remote care, technical aids and removal of architectural barriers.

The case management team informed the physician, nurse or social worker as well as the patient and the main carer about the research project and agreed upon the proposed pathway for the patient. Following this agreement, respective resources were activated. The case management team monitored the process and became the referent for both the patient and his/her carer for all administrative processes. The intervention lasted for periods of six to nine months.

What are/were the effects?

The results of the project underline the effectiveness of the case management programme partly for a significant effect could be shown in only a few variables measured. While the intervention group had fewer office visits and hospital admissions (emergencies) than the control group, no significant differences could be found. However, the case management programme significantly reduced the exclusive use of health care resources and promoted the use of cheaper resources: 55.5% of users were provided social care at home, rather than more expensive health care facilities.

In general, the results illustrate that fragmentation and discontinuity remain constant factors in the Spanish health and social care systems. The road to change has been initiated in the Valencian health system by creating two new professional positions: ‘management nurses’ and ‘continuity nurses’ who apply the case management methodology from a primary health care centre and in hospitals to better connect both spheres between themselves and with social resources.

What are the strengths and limitations?

Strengths

The tested model for integrating social and health resources confirms that the proposal is an appropriate model to address current shortcomings. However, it is evident that there are important gaps that remain yet to be resolved. The testing of the model was limited both spatially and temporarily – a more widespread impact is currently tested through a mathematical model.  

The pilot project has also highlighted specific and well-known barriers that will have to be resolved to facilitate a transition towards a sustainable social-health model. The first has to do with the idiosyncratic corporatism of professionals within both social and health care systems, reciprocal ignorance and distrust in the scope of respective professional duties. For instance, during the pilot project the case management team often experienced resistance by colleagues in primary health and specialised care in health and social centers. It is evident that cultural change and a change of professional attitudes is necessary with an acknowledgement of the added value of team and interdisciplinary work as well as demanding training with the values and methodology of the socio-health model.  

Weaknesses

The pilot project was of course not able to overcome the huge differences in funding and the difference in resources between social and health systems. While in the health system access to the resources and services is an individual right and provided free of charge, social care is means-tested so that the management of an integrated portfolio of resources gets hampered. The inexistence of inter-system structures restricts the coordination and it increases the compartmentalization of the functionality of resources.

Opportunities

The outcomes of the pilot project presented could be further increased if resources would be better adapted to the specific needs of each person (Brown et al., 2003). This would imply a definition of each health and social care services’ profile and to further specify which combination would maximise the patient’s quality of life. For example, almost one quarter (24.6%) of patients admitted to LTC Hospitals presented profiles similar to patients using short-term care in nursing homes, hospital-at-home units or home help services. This means that they could perhaps better be cared for through these services (Garcés et al., 2006).

A more adequate management during patients’ referral pathways would generally improve the use of resources for the population as a whole (Kane et al., 2000).

Threats

One of the main motives for the lack of intermediary and coordinating structures is that governments pay more attention to their functional survival and to annual budgets than to opportunities created by longer-term investments in reforms that would optimise the use of resources and services.

Credits

Links to other INTERLINKS practice examples

• Case management for patients of lower socio-economic status experiencing complex somatic and psychosocial problems (Kompass)
• Case managers for people with dementia and their informal caregivers
• Coordinating Care for Older People (COPA): Team work integrating health and social care professionals in community care
• Local Integrated Delivery Networks – L’Association “Réseau de la communauté sanitaire de la région lausannoise” (ARCOS)

External Links and References

References

• Applebaum R, Straker J, Mehdizadeh S, Warshaw G, Gothelf E (2002) Using High-Intensity Care Management to Integrate Acute and Long-Term Care Services: Substitute for Large Scale System Reform?, Case Management Journal, 3(3): 113-119.
• Brown L, Tucker C, Domokos T (2003) Evaluating the impact of integrated health  and social care teams on older people living in the Community, Health Soc Care Comm, 11(2): 85-94.
• Garcés J (2000) La nueva sostenibilidad social. Barcelona: Ariel.
• Garcés J, Ródenas F and Sanjosé V (2004) Care needs among the dependent population in Spain: an empirical approach, Health Soc Care Comm, 12(6): 466-474.
• Garcés J, Ródenas F and Sanjosé V (2006) Suitability of the health and social care resources for persons requiring long-term care in Spain: an empirical approach, Health Policy, 76: 121-130.
• Generalitat Valenciana (2004) Plan para la mejora de la atención domiciliaria en la Comunidad Valenciana (IMAD), 2004-2007. Valencia: Generalitat Valenciana, Conselleria de Sanitat.
• Glasby J, Littlechild R, Pryce K (2004) Show me the way to go home: a narrative review of the literature on delayed hospital discharges and older people, Brit J Soc Work, 34: 1189-1197.
• Kane RL, Chen Q, Finch M, Blewett L, Burns R, Moskowitz M (2000) The optimal outcomes of post-hospital care under Medicare, Health Serv Res; 35(3): 615-61.
• Walsh EG, Clark WD (2002) Managed Care and Dually Eligible Beneficiaries: Challenges in Coordination, Health Care Financ Rev, 24(1): 63-82.

Website

www.polibienestar.org