Table 1.

Criteria for caseload (Primary Care Trust 1)

• Over 18 years of age

• 2 or more unplanned admissions in last 12 months

• 2 or more long term conditions or other health problems

• Poly pharmacy (4 or more medications as per National Service Framework 2001) [1]

• 4–5 consultations with General Practitioner in last 6 months regarding long term conditions

• Other risk factors that health or social care practitioners may be concerned about i.e. death of carer

NB. 3 or 4 of the above should trigger an assessment for case management

Other areas for consideration

• 2 or more Accident & Emergency attendances in previous 6 months

• Significant impairment of 1 or more Activity of Daily Living

• Patients whose hospital admission exceeds 1 month

• Patients with high intensity care packages

• More than 2 falls in previous 2 months

• Recent exacerbation or deterioration in previous 3 months

• Cognitively impaired and living alone

Exclusion criteria

• Patients with acute mental health problems

• Patients who refuse the service

• Primary cause of referral is alcohol problem

• Needs already adequately met by case management by other professional