The Active Case Management Service (ACM) supports patients with long-term conditions (LTCs) in the community in their own homes.
The ACM service is an integral part of the Integrated Primary Health Care Team and wider health care system. The aim of the service is to care for patients with complex needs, through intensive co-ordination, at a complex health and social care multi-disciplinary team level.
We deal with long term conditions such as Heart Failure, COPD (Chronic Obstructive Pulmonary Disease); Asthma; Peripheral Vascular Disease; Diabetes; Dementia; Renal Failure; Cardiovascular Disease etc.
We use case management ethos, advanced clinical skills and expert LTC knowledge, to develop personal management plans and promote self-care and more appropriate use of accessing health care.
We plan taking into account expressed wishes, dignity, human rights, choices and goals, through effective use of available resources, enabling the patient and/or carer to consider risks to their health and well-being.
The patient and/or carer works with the ACM team to develop personalised management plans to achieve optimum health levels. ACM team members work with Social Services, GPs, nursing home staff and the voluntary sector to support patients and help to prevent unnecessary hospital admissions especially via A&E attendance/non elective (emergency) admissions.
The team works closely with district nurses, other unscheduled care services and independent sector providers. The community teams of Advanced Nurse Practitioners/Community Matrons; Case Managers and Assistant Practitioners are divided into four integrated locality teams within Central Manchester.
The ACM service covers 30 GP practices across the city and only see GP registered patients.
The service runs an open referral policy via the contact assessment form and internally via ICE.
The patient needs to be registered with a GP in the defined geographical area of Central Manchester, and who agrees to continue to maintain overall medical responsibility for care.
Patients are visited in their own homes. If required, patients will be seen whilst in hospital and in other community based units such as intermediate care units.
The service works with the Department of Elderly Medicine and Specialist areas at Manchester Royal Infirmary to prevent unnecessary hospitalisation of elderly patients and to facilitate early discharge when appropriate.
The ACM service works closely with Intermediate Care and District Nursing Services who work together to ensure that patients are moved through the system to create extra capacity for patients requiring case management with high intensity needs, which need to be met by the ACM team.
Findings from the initial patient visit or during subsequent assessments will be discussed with the GP and/or another relevant practitioner as appropriate. Referrals will be made to other professionals/agencies will be made as appropriate following assessment.
Case managers conduct medication reviews with patients and in the first instance. However, case managers may also step patients up when a medication regime is complicated and the additional support of an Advanced Nurse Practitioner/Community Matron is required.
Patients who are considered to be entering the end of life phase and who require intensive daily support will be referred to the District Nursing Service and if required, Macmillan nurses.