As the number of people diagnosed with conditions like asthma, diabetes and heart disease is set to increase by up to 75 per cent in Birmingham, case managers will play a vital role in meeting their needs as part of health reforms.
More than one in four people in the city suffer from such complaints.
Amira Obeid, case manager for South Birmingham PCT, already sees 43 patients a week in their homes but expects that number to soar over the next 25 years.
The new case management system aims to tackle the rising demand on local health services by treating people with chronic long-term conditions at home - and freeing up GPs time, as one healthworker acts as provider and procurer of a patient's care.
Increasing numbers of people with diabetes, respiratory and coronary heart diseases will be supported at home with regular check-ups and medication monitoring, preventing crises and avoidable admissions to hospital.
South Birmingham PCT is introducing this system to support patients in their homes so that they do not find themselves at crisis point, which often leads to repeat-edly being admitted to hospital.
Ms Obeid, who is also an advanced nurse practitioner and nurse prescriber, began work as the PCT's case manager in April seeing vulnerable patients who require intensive support at home.
The 37-year-old, who is based at Lordswood House practice in Harborne and Woodgate Valley Primary Care Centre, said previously patients would wait for a crisis before seeing a doctor or ended up in hospital.
She said: "Most of my case loads are elderly, frail patients who have complex health needs and may have had several falls, so a large part of my job is to try and ease the burden of their disease on them and their family.
"Most of these patients are bed bound and as a result they can't get to their GP's surgery, but now people with long term conditions can access chronic disease management.
"This is about addressing their medical needs and as such should help improve patient outcomes and free up GPs time at their practice.
"This move will enable nurses to expand the roles more fully into taking in some duties that were previously carried out by doctors in the surgery."
Evidence from NHS research shows that case management can dramatically improve lives by reducing emergency hospital admissions and enabling people to return home more quickly.