Case management is the provision of coordinated health and social care by a single health or social care professional
Case managers in the CARE-DEM trial will be employed by NHS organisations, and will work under the supervision of a GP or other clinical lead, and an NHS line manager.
The case manager in the CARE-DEM trial will undertake the following tasks:
Identify people with dementia (PWD) from general practice lists.
Review medical records of PWD +/- their carer(s), noting any gaps in the record and also the involvement of other possible sources of support.
Liaise with other professionals who know the PWD to learn their perspectives on individual or family needs.
Engage with the PWD +/- carer to identify their main concerns or unmet needs.
Update or fill in gaps in GP medical records and where appropriate update social care records.
Analyse information obtained with PWD & carers.
Map support available to and wanted by PWD & carer. Create a personal care or support plan with each PWD & carer, and initiate actions that will provide that support (for example, help with seeking advice about benefits, liaising with the GP about treatment of other conditions and discussion of plans around finance, health and welfare decisions1)
Analyse information obtained with other relevant practitioners (e.g. GP, social worker, care home key worker).
Prioritise individual PWD and 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 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 PWD and carers.
Meet regularly with his/her mentor, to discuss PWD and carers with whom they are working, to review prioritisation, to resolve any problems that have arisen and to plan the end of their role with the PWD 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.