Case management is the provision of co-ordinated health and social care by a single health or social care professional.
The CAREDEM study is a randomised controlled trial of case managment for people with dementia and their carers, conducted in primary care.
Case managers in the CAREDEM trial will be employed by NHS organisations and will work under the supervision of a GP or other clinical lead and a NHS line manager.
The case manager in the CAREDEM trial will undertake the following tasks:
Identify people with dementia from general practice lists.
Review medical records of people with dementia ± their carers, noting any gaps in the record and also the involvement of other possible sources of support.
Liaise with other professionals who know the people with dementia to learn their perspectives on individual or family needs.
Engage with the people with dementia ± their carers to identify their main concerns or unmet needs.
Update or fill in gaps in GP medical records and when appropriate update social care records.
Analyse information obtained from the people with dementia and their carers.
Map support available to and wanted by people with dementia and their carers. Create a personal care or support plan with each person with dementia and his or her carer and initiate actions that will provide that support [e.g. help with seeking advice about benefits, liaising with the GP about treatment of other conditions and discussion of plans around finance, health and welfare decisions (details inserted here to limit the scope for interpretation of the job by those doing it).
Analyse information obtained by other relevant practitioners (e.g. GP, social worker, care home key worker).
Prioritise individual people with dementia and their carers: assess need for action in terms of ‘intensive’, ‘maintenance’ and ‘holding’ (for those already being case managed by other agencies).
Build the care plan into the GP medical records and share it with other disciplines and agencies as needed.
Organise systematic follow-up to review the outcomes of actions taken, meet regularly with the GP or other relevant clinical leads and act as an advocate for the people with dementia and their carers.
Meet regularly with his/her mentor to discuss the people with dementia and their carers with whom they are working, review prioritisation, resolve any problems that have arisen and plan the end of their role with the people with dementia and their carers, as appropriate.
Undertake professional updating and top-up training, as needed.
Meet with and communicate with members of the research team to discuss the case manager role as it develops.
