Although general practice is the focus for health care of older people, it still presents many unresolved problems. The over-75 health check was introduced to try to address some of these, but a recent review confirms that the checks have not been widely successful.1
The care of older people still tends to be piecemeal and in response to crises. The lack of research into the care of older people is particularly evident in primary care. Although this is where most care takes place, little research has been carried out with the involvement of the primary care team.
In 1990, Williams showed that comprehensive case management is the form of assessment that is associated with the fewest ethical objections and is most relevant to individual care.2
Practice nurses are increasingly responsible for running specialist clinics, and their role in the management of individual patients could and is being extended. District nurses are responsible for the regular care of high-dependency patients in the community. This managed care does not generally extend to others.
The NHS Executive (NHSE) recommends that primary health care should be based on integrated managed care which focuses on the physical, psychological and emotional needs of patients, using clinical evidence of effectiveness.
In the USA, nurse case management with guidelines has been shown to decrease resource use and improve patient outcomes.3
Despite some opinion to the contrary, there is convincing evidence of the value of guidelines in improving care. A systematic review4 identified 59 studies covering a range of clinical activities; 55 of these identified improvements in process, dissemination and implementation, and nine of the 11 that measured outcome reported significant improvements.
As part of the NHSE North Thames research and development programme for the health of older people, the Centre for Research in Primary and Community Care at the University of Hertfordshire, together with the Royal Free Hospital, has been commissioned to evaluate a programme of nurse-led case management of older people (COPE) in general practice, using practice guidelines.
The first part of our study has involved the development of clear practice-based guidelines and care pathways for older people for:
- mental health5,6
- palliative care7
- cardiac failure
- chronic pulmonary disease
- locomotive disorders
- leg ulcers
- post-hospital discharge10,11
Guidelines for common problems such as vascular and gastric/bowel problems were also developed.
The evidence-based guidelines specifically for older adults have been selected and regularly updated from the Cochrane Centre, York Centre for Reviews and Dissemination, the North of England Guidelines, the Systematic Review Training Centre and the SIGN guidelines.
Guidelines of the highest scientific quality for each condition are selected, discussed by the steering group and the intervention practices and converted into a user-friendly format for use by the primary care team.
The guidelines are rigorously developed and consistent with the available scientific evidence or, in the absence of such evidence, the best clinical judgment.
Once identified, the guidelines are summarised in the form of useful working algorithms to guide case management. Evaluation is performed by means of a randomised controlled trial involving 12 general practices and several community trusts.
The GP, practice nurse, district nurse, community geriatrician, and others as appropriate, meet regularly (weekly for large practices, monthly for small ones) for case management meetings to agree care pathways and undertake regular review of care.
The practice nurse has responsibility for low-dependency patients seen opportunistically at the practice, while the district nurse has responsibility for high-dependency patients who need to be visited in their own homes.
The aim is to use existing resources in the most focused and effective way possible.
The case management plan is recorded on the electronic medical record and in the written record and made available to all team members and the patient. These records are problem oriented, and it is the task of the case manager to review them regularly to ensure that agreed services and tests are being provided.
Patients over 75 years of age are identified from the six intervention practices for case management, and a further six matched practices provide comparative (control) patients. The practices include large (five or more GPs) and small (one or two GPs) practices sampled from inner-city practices and suburban and rural practices.
Retrospective data for the previous year and prospective data for the following year will be collected from both intervention and control practice patients aged over 75 years, to compare resource use.
A random sample of one in five older adults, from both intervention and control groups, is being assessed both at baseline and follow-up, for outcomes, patient quality of life and patient and carer satisfaction.
The cost-effectiveness analysis will include all health services' use – prospective and retrospective – for all patients, as well as data collected on formal and informal care and quality of life from the intervention and control samples.
Following the trial the findings will be presented to and discussed with the intervention and control practices, and disseminated widely through conferences, papers and seminars.
- The COPE Project team:
Centre for Research in Primary and Community Care, University of Hertfordshire
Professor Joy Townsend
Dr Morag McKinnon
Department of Primary Care and Population Studies, Royal Free Hospital, London
Dr Steve Iliffe
Dr Kate Walters
- Iliffe S, Gould MM, Wallace P. Evaluations of the 75 year old over checks; report 1 examples of good practice and their implications for future policy. London: Department of Primary Health Care, UCLMS/RFHSM, 1997.
- Williams I. Assessment – ethical consideration. Presentation to the RCGP Conference on Assessment of the Elderly, November 1990.
- Swindle DN et al. Nurse care management. J Case Manage 1994; 3: 50-5.
- Grimshaw J, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of vigorous evaluation. Lancet 1993; 342: 1317-22.
- Blanchard MR, Waterman A, Mann AH. The effect of primary care nurse intervention upon older people screened as depressed. Int J Geriatr Psychiatry 1995; 10: 289-98.
- Banerjee S, Shamash K, Macdonald AJD, Mann A. Randomised controlled trial of effect of intervention by psychogeriatric team on depression in frail elderly people at home. Br Med J 1996; 313: 1058-61.
- Robinson L, Stacey R. Palliative care in the community: setting practice guidelines for primary care teams. Br J Gen Pract 1994; 44: 461-4.
- Feder G, Griffiths C, Highton C et al. Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in East London. Br Med J 1995; 311: 1473-8.
- North of England Asthma Guideline Development Group. North of England evidence-based guidelines development project: summary version of evidence-based guidelines for the primary care management of asthma in adults. Br Med J 1996; 312: 762-6.
- Oakley A, Dawson MF, Holland J et al. Preventing falls and subsequent injury in older people. Qual Healthcare 1996; 5: 243-9.
- Townsend J, Piper M, Frank A et al. Reduction in hospital readmission stay of elderly patients by a community based hospital discharge scheme: a randomised controlled trial. Br Med J 1988; 297: 544-57