Healthcare consumption, experiences of care and test of and intervention in frail old people. Implications for case management

Abstract: The overall aim of thesis was to explore frail older people’s experiences of receiving healthcare and/or social services and to investigate healthcare consumption and costs in both men and women and in different age groups in the two years prior to the introduction of long-term municipal care. A second aim was to explore a preventive intervention in a pilot study using case managers to older people with functional dependency and repeated healthcare contacts. Study I was qualitative and comprised 14 people (mean age 81) who were interviewed about their experiences of the healthcare and social services delivered to them. The results were analysed using content analysis. A cross-sectional, comparative design was used in studies II and III, which comprised 362 people who received a decision about the provision of municipal care or/and services during 2002-2003 and the participants were drawn from the Swedish National Study of Aging and Care (SNAC) and the county council register of healthcare consumption and costs. Study IV was a pilot trial with an experimental design and comprised 35 people who were consecutively and randomly assigned to either an intervention (n=19) or a control (n=16) group. Two nurses worked as case managers and carried out the intervention, which had four dimensions. Data were collected at baseline and after the intervention had been in place for about three months. Study I showed that the experience of receiving healthcare and/or social services in old age could be interpreted according to the overall theme “Having power or being powerless”, divided into three main categories: Autonomous or without control in relation to the healthcare and/or social service system; Confirmed or violated in relation to caregivers and Paradoxes in healthcare and social services. The results from Study II showed that about 50% of the acute hospital stays occurred within the five months prior to receiving municipal care. The men (n= 115, mean age 80.8) had significantly more bed days in hospital, more diagnoses and contacts with other staff groups besides physicians in outpatient care compared to the women (n=247, mean age 83.8). The results from study III showed that 13% of the sample had overall higher healthcare costs throughout the two years of observation. A majority (58% for the women and 54% for the men) of the costs for acute inpatient care occurred within five months prior to municipal care. The results from Study IV showed no differences between groups at baseline. Those included reported low life satisfaction, low perceived health and were also at risk of suffering from depression. The Life Satisfaction Index, Geriatric Depression Scale-20 and the ADL staircase had satisfactory internal consistency. Healthcare staff must be aware of the risk that older people loose control over their life situation when receiving healthcare and/or social services from various agencies. Preventive interventions and a more empowering approach are seemingly needed. This requires continuity and accessibility on an individual and organisational level. Early detection through a systematic clinical assessment, a more proactive and integrated care and applying preventive interventions to people in a transitional stage of becoming increasingly dependent on continuous care and services seems urgent to prevent escalating acute hospital admissions and thereby costs. The intervention had a feasible design. The sampling procedure led to similar groups and the measures were reliable to use. Both groups had a low life satisfaction, a low self reported health and were at risk of having a depression and could benefit from preventive interventions. No effects were found on self perceived health and depressed mood after three months. This might be due to the follow up time being too short. Further investigations about the content of the interventions are needed in the future.