Case Management for Chronic Disease
Case management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health and social care needs.
As the population ages, there is a growing need for systems and processes that can successfully meet the medical and social care requirements of people with chronic conditions. Mrs Orlov's case highlights the significant challenges for individuals in maintaining optimal health, functional capacity, quality of life and independence. Often they require coordinated assistance and support to achieve these outcomes.
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| Sarah cares and interprets for her mother Mrs Orlov who has chronic complex medical problems resulting in frequent hospital admissions. | Sarah is overwhelmed with managing her mother’s medical care. Mrs Orlov’s health deteriorates and she is hospitalised again. | The heart failure nurse realises that Sarah needs support. A case conference is called and it is decided to engage a community case manager. | Mrs Orlov is discharged to respite care. The COPs case manager work with Sarah, Mrs Orlov, the hospital team and GP to plan a successful return home. | The case manager arranges home support services for Mrs Orlov and Sarah. The GP monitors the new treatment regime, the heart failure team provides education and support. | The case manager coordinates the development of a long term care plan. Mrs Orlov is stable and Sarah is managing well. The case manager and heart failure nurse visit to check how they are managing. |
Implementing the Case Management Model of Care
Use these implementation guidelines, tools and hints to help you to make Case Management happen.
Download the Case Management Model of Care 
(2.4MB)
Literature - that validates the Case Management Model of Care
- View references and resources used to develop the Case Management Model of Care.
Contact
Principal Project Officer, Integrated Aged and Chronic Care
Health Services Performance Improvement Branch, NSW Health
Phone: 02 9391 9832
