This report from the Department of Health assesses the pilot projects of case
management for frail elderly patients in nine primary care trusts. The pilots
were modelled on the Evercare programme which operates in the United States.
The programme improves care for frail elderly people, most of whom have multiple
medical and social problems, receive fragmented, episodic care and are often
admitted to hospital for reasons that could be prevented with better care. This
group of people also generates large costs. Two-thirds of patients admitted to
hospital as medical emergencies have long-term conditions, and 70% of people
over 65 in the UK have more than one long-term condition. The programme aims to
match support with need, providing personalised, yet systematic health and
social care.

The main findings from the assessment are that patients and carers expressed
great satisfaction with the programme and nurses reported that their skills were
enhanced and that they were able to improve the care of patients. GPs generally
thought that the care of patients was improved and their workload lightened. The
report does show a reduction in unplanned admissions for some NHS Evercare
patients, however it is not possible to conclude that this was due to the
Evercare approach.

The report recommends ways in which the programme could be improved, including
finding better ways of identifying patients most at risk, commissioning more
effectively, and providing nurse coverage 24/7.

The report is available at:
http://www.dh.gov.uk/assetRoot/04/11/42/24/04114224.pdf