There is a lot we still do not know about how national director for health and work Dame Carol Black’s proposed Fit for Work health service will actually work when pilots start this summer. Where will they be sited? Who will run it? Who will staff it? What services will it offer? And who will fund it? But one thing we do know is that, whatever final shape or form it takes, case management will play a central part within it.
As the government explained in its ground-breaking response to Black’s plans, published in November last year: “The Fit for Work service pilots will provide case-managed, multidisciplinary support, and various models will be tested. All pilots will be comprehensively evaluated.”
It’s not just within Fit for Work that case management is becoming a bit of an occupational health (OH) buzzword right now, either. Case management has become an integral part of NHS OH provision within Scotland (see case study, page 21). The Department for Work and Pensions (DWP), which has been working with the UK Vocational Rehabilitation Council on drawing up common standards for vocational rehabilitation, has also made it clear that it sees active case management- including close liaison between employee, manager, OH and others – as a cost-effective way of helping people return to work.
For example, the DWP’s Pathways to Work programme, which helps to get people off incapacity benefit, uses case management extensively. Many commercial OH providers, too, now employ dedicated case managers to work alongside OH teams, while big-name firms such as Anglian Water and Scottish Power have all used case management as an effective tool for reducing their absence costs.
But what exactly is case management within the OH context, and isn’t it just what most good OH nurses have always done anyway? Moreover, if OH professionals are suddenly going to be working much more closely with case managers, is there an argument for them to be properly qualified and accredited?
According to the Case Management Society of the UK, case management is defined as “a collaborative process which assesses, plans, implements, co-ordinates, monitors and evaluates the options and services required to meet an individual’s health, care and employment needs”.
But this does not necessarily mean it is a concept particularly well understood by health professionals, let alone by employers, points out Joy Reymond, head of rehabilitation services at Unum.
“There is a lot of confusion among employers, and even health professionals, about what OH is and what case management is within that,” she says. “It can be, to an extent, whatever a particular group of professionals decide it is.”
To complicate matters, the term ‘case management’ will often mean something different within the NHS, which has traditionally focused on disease management and, more recently, condition management, argues Reymond.
“Because NHS professionals tend to have such a clinical focus, their case management therefore also will be more clinical,” she says. “Within OH or vocational rehabilitation, there will be much more of a distinct emphasis on non-clinical outcomes. But the principles of case management should be the same across the different activities.”
It also differs, albeit subtly, from long-term condition management. “For example, if someone has chronic back pain and has had that condition sufficiently long that it is no longer susceptible to physiotherapy or surgery, the individual will need to adapt, both physically and mentally, if they are to successfully manage their symptoms and limitations over the long term. In such a case, this long-term condition management will be an important part, but not the only part, of a case manager’s role.
The case manager may also need to take into consideration other issues which the individual is facing, such as the possibility of returning to work, or re-entering the world of work. “In this respect, good condition management will provide a very good foundation for successful case management and return to work,” explains Reymond. “In summary, case management is more the management of the whole case, of which condition management would be a part.”
Given all this, where should OH stand in the case management equation? Is it an opportunity, a challenge, a threat, or all three? According to Jane Melvin, managing director of healthcare services company CareMax, which also specialises in offering case management training, case management is something OH nurses and physicians should be embracing, yet there is also a need for greater clarity over the standards, qualifications and accreditation of what is a relatively new function.
“The way Dame Carol has described it is very much as a hub and spoke on a wheel,” she says. “Case management is the hub, and there is no reason why that cannot be OH professionals or NHS case managers.”
“It is an opportunity all round, both for case management companies as well as for the OH sector,” agrees Andrew Pemberton, director of specialist rehabilitation firm Argent Rehabilitation. “Within both Dame Carol’s original report and the government’s response, it is really good simply to hear the phrase ‘case management’ being used. If you had gone back even as little as five years ago and had started talking about case management, people would have been asking: ‘What do you mean?’,” he adds.
To this end, CMS UK has been working to create a set of national standards and a certification process for case managers, which it hopes to launch during this year. There are also discussions continuing with various UK universities around the creation of a new postgraduate certificate in case management, something that could, in turn, evolve into a full-blown diploma.
“We are not saying that every case manager out there who has been working for, say, 20 years suddenly needs to have a postgraduate certificate, but this is something that CMS UK is looking to hang its hat on and which could become a kitemark,” says Melvin, who is a member of CMS UK.
The central position given to case management within both Black’s Working for a Healthier Tomorrow report and the government’s response does mean there is now a need for greater liaison and understanding between OH and case management, argues Carole Chantler, chair of CMS UK.
“Case management is not a threat,” she stresses. “There are many OH nurses who already work in a case management role but have just not had that recognised. So there needs to be some sort of regulation to ensure people’s roles are clearly identified. There is a lot of overlap between the two roles.”
Now would be a good time for OH professionals to look at their case management skills, particularly their problem-solving and mediation skills, and ask themselves whether these need to be improved, advises Reymond.
“To be successful in fit-for-work case management, the professional must understand how an organisation ticks,” she says. “If you do not understand how the whole organisation works, and how you can influence that to the benefit of all parties, you can end up sitting in splendid medical isolation, unable to help either party resolve their return-to-work problems. The model for Fit for Work will, I feel, emphasise a new model for OH. The question is, will people embrace it?”
What would also be helpful would be some really effective cost-benefit analysis on what elements of case management work best and in what scenarios, argues Pemberton.
“There are already OH professionals and companies that do case management,” he points out. “A lot of OH nurses would argue that case management is just a different label, although there are differences. OH nurses should really see it as just another area or speciality that they can start to focus on.”
However, what is not clear is what effect this heightened profile of the case manager could in time have around channels of accountability and the day-to-day working of OH practitioners. Who, in effect, will be calling the shots – the case manager, or the OH professional (particularly if the case manager believes the OH practitioner is being overly negative or passive about getting someone back into work)?
There are no easy answers to this and, certainly, the Scottish OHSxtra case management pilot (see above) found effective communication and collaboration between OH and case managers was one of the most challenging aspects of running an effective case management programme.
In fact, even though the case managers and OH were working in the same building, the relationship, as the pilot evaluation report concluded, was not as close as it might have been. “Some clients were under the care of both OHSxtra and traditional OH it was possible for neither professional group to know that the other was involved, and therefore to work less effectively,” it pointed out.
There were administrative errors in the filling out of many OHSxtra client eligibility forms which meant OH often had no idea that a client was also being supported by OHSxtra. “This communication breakdown meant OH staff could have been supporting clients who were also receiving interventions from other service providers through OHSxtra. This highlights the importance of sharing records and two-way communication between OH and OHSxtra case managers,” the report recommended.
And there were also, at least initially, tensions around patient confidentiality and the extent to which OH should allow case managers access to case notes.
Ultimately, just as the future generally for OH appears to be much more collaborative and multidisciplinary, so its relationship to case management and to case managers is one that is rapidly evolving and will, it is clear, have an increasingly important role in the future. The challenge for OH therefore will be whether it digs its heels in and is dragged along kicking and screaming or whether, as Katharine Cassinelli, clinical services manager at ATOS Healthcare suggests, it sees this as an opportunity to mould and shape how case management is used in the future.
“I think case management will definitely have a high profile going forward. It will evolve from what it is at the moment, and the role of case manager will evolve too,” she argues. “There are already a lot of OH practitioners out there who may not have a qualification in case management, but are nevertheless very good at it. So there is definitely an opportunity for OH to be leading on this,” she adds.
Case study: OHSxtra
Case management was at the heart of OHSxtra, a pilot case management-based OH health programme run by NHS Fife and NHS Lanarkshire between January 2006 and May 2007.
Case managers worked alongside existing OH services, with NHS workers being offered access to services such as physiotherapy, occupational therapy, cognitive behavioural therapy (CBT) and counselling.
The case managers oversaw the delivery of the service, agreed its extension or curtailment and, where necessary, undertook formal progress assessments.
During the pilot, some 540 employees were referred in, three-quarters with musculoskeletal disorders and a quarter with mental health problems. By its completion in 2007, 250 had been discharged 142 were still active within it 126 had voluntarily withdrawn and 22 were either ineligible or had been inappropriately referred.
Most positively, of those who had been absent from work before entering the programme, 72% had returned to work, and of those who had been off for more than 21 working days, 65% had returned. Nearly all – 99% – of those who had been at work but struggling, had remained in work.
A significant number were also not taking any medication post-intervention compared with pre-intervention, the study found.
In conclusion, according to the evaluation report, using case managers was found to be both effective and resulted in “significant improvements in health”, as well as making savings of £1.66 for every £1 spent.
Since then, the service has been taken on within 16 health boards within Scotland, explains Dr Alastair Leckie, director of Fife and Tayside OH provider OHSAS.
Most pertinently for OH professionals, it has also been modified so that, rather than using specialist case managers to deliver the case management, it is now led by existing healthcare professionals.
“During the pilot it was the case manager who accessed the physiotherapy, CBT, counselling or whatever it was, and really ran the show. But what it has evolved into is case management becoming an approach, rather than a single individual,” he says. “It is about OH nurses, physiotherapists and others using case management within their existing role, rather than having a dedicated case manager.”
What’s more, Leckie questions whether it is really necessary to go off and do a fully fledged postgraduate qualification. Within OHSxtra, for example, practitioners are simply given five days of case management training.
“What we feel is that, for many health professionals, they are already doing a lot of clinical case management, so it is not necessarily that much of a leap to non-clinical case management,” he argues.
“Some people will already be doing it intuitively because they will know what the outcome is they are looking for. The skills are largely there from the clinical point of view, so it is just about refocusing them, reforming people’s concepts, and giving them different outcomes,” he adds.
In 2006, CMS UK produced a set of best practice guidelines for case managers, which suggest that a case manager should, among a range of responsibilities:
Accurately appraise the needs of the case
Ensure their skills, competencies, experience and qualifications match what is required
Ensure there is transparency and clarity in the referral goals
Maintain confidentiality throughout
Undertake an initial assessment as early as possible to establish baseline needs
Hold regular multi-agency, roundtable meetings on progress of the rehabilitation process.