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ℹ️ Introduction
This article explains how the Ardens Case Management resources can support the identification, assessment, care planning and ongoing review of patients receiving coordinated case management.
Background
Case management is a coordinated approach to supporting patients with complex health or care needs who may require input from several professionals, services or organisations.
It can involve:
Identifying patients who may benefit from additional support
Completing a holistic assessment of their health, care and wider needs
Assigning responsibility for coordinating their care
Agreeing personalised goals and a care plan
Coordinating multidisciplinary input
Reviewing the patient’s needs and progress over time
Ending case management when the additional coordination is no longer required
Case management may form part of local proactive care or Integrated Neighbourhood Team (INT) arrangements. INTs bring together professionals from services such as primary care, community health, mental health, social care and the voluntary sector to provide more coordinated care closer to home.
The patients prioritised for case management will depend on locally agreed pathways. This may include patients with frailty, multiple long-term conditions, palliative or end-of-life care needs, a high risk of hospital admission or other complex health and social care needs.
For further background, see the Neighbourhood Health Framework.
How Ardens Can Help
The Ardens Case Management resources support a structured approach to identifying and managing patients with complex needs. They provide tools for recording register status, completing holistic reviews, coordinating personalised care and multidisciplinary input, and monitoring the case management caseload.
How to Access the Resources
Template
Access using one of the following methods:
Patient status alerts - Click the icon under the patient's name if the patient is already on the Case Management register
F12 Favourites - Press F12 and add the template to your favourites (access this support article for instructions on using the F12)
Search bar - Use the search bar in the bottom-left corner of SystmOne and search for 'Case Management'
Auto-consultations - Click Auto-consultations > ardens GENERAL > MDT Case Management
Toolbar - Add the template to your toolbar
Reports
Navigate to Clinical Reporting > Arden's Ltd > Team | Meetings > MDT case management
👨⚕️Recognition
Patients who may benefit from case management are often already known to the practice through other registers, such as frailty or palliative care. Ardens helps practices find these patients proactively and decide, in line with local criteria, whether case management is appropriate.
Case Finding
The Consider reports in the MDT case management folder identify patients on the following registers who are not on the Case Management register:
Avoiding unplanned admissions
End of life
Safeguarding adult
Safeguarding child concern
Safeguarding child protection plan
Severe frailty
Virtual ward
These searches are designed to support proactive case finding and help practices identify patients who may benefit from case management. Inclusion in a search does not automatically mean that a patient should be added to the Case Management register. Practices should review each patient individually and apply their locally agreed criteria when deciding whether case management is appropriate.
Register
Once the decision has been made to start case management, open the Case Management template to record the patient's referral and register details on the Home page.
Select Case management started within the Case management register field to add the patient to the active Case Management register.
The Details section allows you to add further information such as details of any proactive care, continuity of care or communication needs.
Links alongside the fields provide access to further Ardens templates where a more detailed assessment or care plan is required.
⚠️ Please note: recording a case management referral or proactive care needs assessment does not by itself place the patient on the active Case Management register. Active register status is determined by the Case management started and Case management ended codes.
🩺Management
Once a patient is on the register, the template supports coordinating their care, from holistic assessment through to personalised care planning and multidisciplinary discussion.
Alert
When a patient is currently receiving active case management (where Case management started is the most recent register code), the On Case Management Register alert and Case Management icon are displayed in the patient demographic box in the top right of SystmOne.
Selecting the alert opens the Case Management template, allowing the patient’s information to be reviewed or updated.
⚠️Please note: If case management is subsequently restarted, recording a new started code will cause the alert to display again.
Review
A holistic review builds a full picture of the patient's clinical, functional and social needs, and highlights where more support or a more detailed assessment may be needed.
The Review page of the template is used to record details of the initial or ongoing review, including areas such as frailty, mobility or safeguarding.
Care Plan
A personalised care plan records what matters to the patient and the support agreed with them, so everyone involved in their care is working towards the same goals.
Use the Plan page of the template to record the care and support agreed with the patient and the professionals involved in their care. Links are available to access forms such as ReSPECT and Treatment Escalation Planning.
MDT Meeting
Where a patient needs input from several professionals, the MDT Meeting page of the template supports a structured discussion and a clear record of agreed actions, who is responsible and the follow-up arrangements.
Use the MDT Meeting page to document the professionals involved, the reason for discussion and the key issues identified.
To ensure that recently entered information is included in the MDT Plan, select OK to save the template, reopen it and then select Print MDT Plan.
End Case Management
Case management should end once the patient no longer needs the extra coordination. Recording the end code keeps the register accurate and keeps the patient's history in their record.
When the patient no longer requires active case management, return to the Home page and select Case management ended in the Case management register field. This removes the patient from the register and the alert will no longer display.
📈 Evaluate
Ardens reports and dashboards help practices monitor their case management caseload, check reviews are up to date and identify patients who may need to be considered for case management.
Reports
The MDT Case Management reports help practices identify patients to consider, monitor the active register and track review activity.
Insights
For organisations using Ardens Manager, the INT Dashboard gives a population-level view of case management activity across the practice and neighbourhood team.
It can help identify patients who may be suitable for a comprehensive needs assessment and referral, as well as providing oversight of:
Patients currently on the Case Management register
Patients no longer on the register
Recent Case Management review activity
For further information, see the Ardens Manager – INT Dashboard article.
❓ FAQs
Which patients should be added to the Case Management register?
This depends on your locally agreed case management pathway. Appearing in a Consider report does not mean a patient must be added.
Why has a patient appeared in a Consider report?
They are on a related register, such as severe frailty or end of life, but not on the Case Management register. Review the patient and decide whether case management is appropriate.
Does a referral or proactive care needs assessment add the patient to the register?
No. Only Case management started adds the patient to the active Case Management register.
How do I remove a patient from the register?
Record Case management ended in the Case management register field on the Home page, after the patient's most recent Case management started code. This also removes the alert.
Can a patient be added again after case management has ended?
Yes. Record a new Case management started code and the patient will return to the register and the alert will display again.
Why is the On Case Management Register alert still showing?
The most recent register code is Case management started. Record Case management ended if case management has finished.
Does the Case Management template replace the LTC or Future Care Planning templates?
No. It provides an overview and links to the detailed templates, which should still be completed where appropriate.
Does every patient need to be discussed at an MDT meeting?
No. This depends on the patient's needs and your locally agreed pathway.
Can the template show the patient's recent GP appointments?
Not directly. In SystmOne, view these in the patient's administrative tree under Appointments, Visit & Task History.
🏫 Additional Support
Book training for your GP practice, PCN or ICB
Contact our Support Team for support in real time