Active Case Management (ACM)
The Active Case Management Service (ACM) supports patients with
long-term conditions (LTCs) in the community in their own
The ACM service is an integral part of the Integrated Primary
Health Care Team and wider health care system. The aim of the
service is to care for patients with complex needs, through
intensive co-ordination, at a complex health and social care
multi-disciplinary team level.
This is achieved by using case management ethos, advanced
clinical skills and expert LTC knowledge, to develop personal
management plans and promote self-care and more appropriate use of
accessing health care.
We plan taking into account expressed wishes, dignity, human
rights, choices and goals, through effective use of available
resources, enabling the patient and/or carer to consider risks to
their health and well-being.
The patient and/or carer works with the ACM team to develop
personalised management plans to achieve optimum health levels. ACM
team members work with Social Services, GPs, nursing home staff and
the voluntary sector to support patients and help to prevent
unnecessary hospital admissions especially via A&E
attendance/non elective (emergency) admissions.
The team works closely with district nurses, other unscheduled
care services and independent sector providers. The community teams
of Advanced Nurse Practitioners/Community Matrons; Case Managers
and Assistant Practitioners are divided into four integrated
locality teams within Central Manchester.
The ACM service covers 30 GP practices across the city and only
see GP registered patients.
Moss Side Health Centre
Chorlton Health Centre
Monday to Friday 8.30 am to 5.00 pm (excluding bank
Advanced Nurse Practitioner/ Professional Lead/ Integrated
Manager, Moss Side, Rusholme and Hulme, Julie Harrison: 07891
570224 or email@example.com
Advanced Nurse Practitioner, Donna Oppizio, Moss Side, Rusholme
and Hulme Locality: 07807 165739
Advanced Nurse Practitioner, Glen Oates, Gorton and Levenshulme
Locality: 07967 390937
Advanced Nurse Practitioner, John Timmins, Gorton and
Levenshulme Locality: 07813814411
Advanced Nurse Practitioner, Gillian Lee, Chorlton and Whalley
Range Locality: 07815 835695
Active Case Management Central District
ANP Clinical Lead Head of Service: Julie Harrison 07891
Lorraine Smith, ANP Lead, 07970 146624
Donna Oppizio, ANP Lead, 07815 841532
Glen Oates, ANP Lead, 07967 390937
Bromley Parsons, ANP Lead, 07815 841538
We deal with long term conditions such as Heart Failure, COPD
(Chronic Obstructive Pulmonary Disease); Asthma; Peripheral
Vascular Disease; Diabetes; Dementia; Renal Failure; Cardiovascular
The service runs an open referral policy via the contact
assessment form and internally via ICE.
The patient needs to be registered with a GP in the defined
geographical area of Central Manchester, and who agrees to
continue to maintain overall medical responsibility for care.
Patients are visited in their own homes. If required, patients
will be seen whilst in hospital and in other community based units
such as intermediate care units.
The service works with the Department of Elderly Medicine and
Specialist areas at Manchester Royal Infirmary to prevent
unnecessary hospitalisation of elderly patients and to facilitate
early discharge when appropriate.
The ACM service works closely with Intermediate Care and
District Nursing Services who work together to ensure that patients
are moved through the system to create extra capacity for patients
requiring case management with high intensity needs, which need to
be met by the ACM team.
Findings from the initial patient visit or during subsequent
assessments will be discussed with the GP and/or another relevant
practitioner as appropriate. Referrals will be made to other
professionals/agencies will be made as appropriate following
Case managers conduct medication reviews with patients and in
the first instance. However, case managers may also step patients
up when a medication regime is complicated and the additional
support of an Advanced Nurse Practitioner/Community Matron is
Patients who are considered to be entering the end of life phase
and who require intensive daily support will be referred to the
District Nursing Service and if required, Macmillan nurses.
Awards / Recognitions:
Gold Standard for Governance 2009, 2010
Health Foundation Shine Award 2010
Nursing Times Awards 2011