Holistic support for people with multiple and complex needs

Many people who have complex life and health issues are often supported in a linear way.  With “assessment and onward referral” their predominant experience people often find themselves passed from one agency to the next with a lack of coordination of their needs and care.

In 2007 we pioneered a more holistic way of working with people who had complex life issues including health, housing and financial difficulties.  We invested two years in researching and developing new methodologies in partnership with The College of Holistic Medicine in Glasgow. This resulted in the creation of a ‘Health Case Manager’ role and we piloted our approach of providing long term continuous holistic assessment and case management.

The Case Management process begins with an holistic assessment ( see video) which has been designed to create a partnership between the case manager and the client that starts by building a picture of their current life situation and their relationship to looking after themselves. The holistic assessment identifies things that would improve quality of life for the person in the short and medium term. The person’s priorities are scored and the case manager and the client develop a plan together of which areas to tackle first. Introductions are made to support agencies (rather than referrals) and if necessary the case manager will accompany the person to their first appointment with a support agency. (see Resources for additional videos)

This way of working has produced transformational results for people who had spent years bouncing round the system from one agency to another.  

Central to our way of working is recognition that tackling health inequalities cannot be delivered by any one organisation working on its own; it requires multi-agency and multi-disciplinary approaches with shared principles and values; strong effective leadership; and community involvement. The model should address the ‘gradient’ of health inequalities as well as the ‘gap’ by providing;

• specific support and interventions for individuals and families
• strengthened universal and some specialist services
• and social capital building

The model is based on the premise that 10% of the population in a deprived area will be very vulnerable and require intensive support; 40% will be potentially vulnerable and require strengthened services; and 50% will demonstrate resilience. It is recognised that some people will move in and out of all these categories but gradually over time there should be a general improvement, therefore less people in the 10% cohort.

Our Case Management Service was formally evaluated in 2013 by a public health consultant in Aberdeen University. The evaluation highlights high levels of patient satisfaction with  continuity of care and illustrates the transformational journeys of many patients through case studies.

Currently operating the service in Craigmillar and Portobello, we are working in partnership with the Scottish Government and the National Health Service to extend the benefits of HCM to other communities.