Case management for frail older people. Effects on healthcare utilisation, cost in relation to utility, and experiences of the intervention
Abstract: The overall aim of this thesis was to investigate healthcare utilisation patterns and to explore the effects of a case management intervention for frail older people on healthcare utilisation and costs in relation to utility. A further aim was to explore the older people’s and case managers’ experiences of the intervention. Study I was a quantitative study comprising ten age cohorts aged between 60 and 96 years (n=1402). Baseline data and data on number and length of hospital stays for the six subsequent years were collected. Two pairs of groups; those who were dependent/independent in activities of daily living (ADL), and those at risk/not at risk of depression. In Studies II and III 153 people were randomly allocated to either a control group (n=73) or a group that received a case management intervention (n=80). Inpatient and outpatient healthcare utilisation data (Study II) and costs (Study III) for one year before baseline and for the study year were collected from registers. Data concerning health-related quality of life (HRQoL) used for calculations of Quality-adjusted life-years (QALY), informal care, municipal home care and municipal home services (Study III) were collected through structured interviews at baseline and 3, 6, 9 and 12 months after baseline. Study IV had a qualitative design and interviews were made with 14 participants who had received the case management in Studies II and III. Also six case managers were interviewed about 15 different participants, whom they had met in the intervention. Study I revealed similar utilisation patterns among those dependent/independent in ADL and those at risk/not at risk of depression with more hospital stays among ADL-dependent persons and those at risk of depression. Age was the only universal predictor for healthcare utilisation in all regression models. Other predictors found were previous healthcare utilisation and various symptoms, various diagnostic groups and various physical variables. Studies II revealed that the intervention group had a significantly lower mean number and proportion of emergency department visits not leading to hospitalisation, and lower mean number of visits to physicians in outpatient care. For the whole study year the intervention group had significantly less help with self-reported informal care in terms of provided hours and costs for help with Instrumental ADL (IADL). No significant differences were found for total cost or QALY of the one-year study. In Study IV the experience of the case management intervention was interpreted in two content areas: providing/receiving case management as a model and working as, or interacting with, a case manager as a professional. The findings in Study IV constituted four categories: case management as entering a new professional role and the case manager as a coaching guard, as seen from the provider’s perspective; and case management as a possible additional resource and the case manager as a helping hand, as seen from the receiver’s perspective. Case management appears to have some impact on healthcare utilisation, informal care, and is cost neutral. This may be explained by the intervention providing interpersonal continuity, coordination of care, someone that discovers problems, support in a long term strong relationship and the case managers’ ability to work in close collaboration with primary care.
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