ABSTRACT

This chapter explores principles behind case management and disease-specific care management including new and existing nursing roles and the importance of multi-disciplinary team involvement. It reviews the existing nursing roles such as district nursing and practice nursing in meeting the needs of people with Long-Term Conditions (LTCs), in addition to the community matron/Advanced Primary Nurse (APN) role. The term 'case management' originates from the USA, with its roots in social care, as a method of delivering holistic individualized care, and it tailors to the needs of people with complex health and social care problems. The disease-specific care management involves providing people who have a complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams and disease-specific protocols and pathways, such as the National Service Frameworks (NSFs) and Quality and Outcomes Framework (QOF). Services in Australia improve care coordination for all those with LTCs, with plans to provide integration and continuity of prevention and care.