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Case management for frail older people. Effects on healthcare utilisation, cost in relation to utility, and experiences of the intervention

Sandberg, Magnus LU orcid (2013) In Lund University Faculty of Medicine Doctoral Dissertation Series 2013:97.
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... (More)
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.



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 the case managers’ experiences of the intervention.



Study I was a quantitative study comprising ten age cohorts aged between 60 and 96 years (n=1402) drawn from the Swedish National Study on Aging and Care (SNAC). Baseline data were collected between 2001 and 2003 and data on number and length of hospital stays were collected for the six years after the baseline year. The sample was divided into two pairs of groups; those who were dependent/independent in activities of daily living (ADL), and those at risk/not at risk of depression. The six years period of healthcare utilisation was also divided into utilisation 1-2, 3-4, and 5-6 years after baseline. Studies II and III had an experimental design where 153 people were consecutively and randomly allocated to either a control group (n=73) or a group that received a case management intervention (n=80). Included were those aged 65+ years who lived in their ordinary homes, were dependent in two or more ADL, and had had at least two hospital stays, or four physician visits, in the previous year. Data concerning inpatient (hospital stays and length of stay) and outpatient healthcare utilisation (contacts with physician or other healthcare professionals, and emergency department visits) (Study II) and costs (Study III) for the year before baseline and for the one year study 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 intervention in Studies II and III, and six case managers who had performed the intervention. The case managers were interviewed about a total of 15 different participants, whom they had met in the intervention. The interviews were analysed with content analysis.



Study I revealed a significant increase in hospital stays in all groups over time. ADL-dependent persons and those at risk of depression had significantly more hospital stays, except for those at/not at risk of depression in years 2, 4 and 5. Main predictors for healthcare utilisation 5-6 years after baseline were age, previous healthcare utilisation and various symptoms; and at 1-2 and 3-4 years after baseline, age, various diagnostic groups and various physical variables. Thus healthcare utilisation patterns seem to be similar for the different groups over the six years, but it is difficult to find universal predictors.



In Studies II and III there were no differences between the interventions and control groups were found at baseline (in demographics, baseline characteristics, in or outpatient healthcare utilisation, utilisation in informal care, municipal home care, municipal home services or costs). The results showed that, compared to the control group, the intervention group had significantly lower mean number and proportion of emergency department visits not leading to hospitalisation 6-12 months after baseline (0.08 vs. 0.37, p=0.041 and 16.7 vs. 46.9%, p=0.012, respectively). The intervention group also had a significantly lower mean number of visits to physicians in outpatient care 6-12 months after baseline (4.09 vs. 5.29, p=0.047). The intervention group had significantly less help with self-reported informal care in terms of provided hours and cost for help with Instrumental ADL (IADL) during the one-year study (200 vs. 333 hours per year, p=0.037; €3927 vs. €6550, p=0.037). There were no significant differences between the intervention group and control group in terms of total cost of the one-year study, or QALY.



Study IV showed that the experience of the case management intervention could be interpreted according to 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. Each category constituted different subcategories, all reflecting aspects of the respective category.



The results indicate that the population of older people are heterogeneous which may be one reason for the difficulties to find universal predictors for healthcare utilisation. This may also be the reason for the lack of effects on hospital stays, length of stay, and HRQoL in the case management studies. However, the case management intervention appears to have effects in emergency department visits not leading to hospitalisation, visits to physician in outpatient care, in informal care, and is cost neutral. This indicates that the case management intervention seems to have impact on the situation; not only for the older person, but also their informal caregivers. Possible features of the case management intervention that may explain these effects may be interpersonal continuity, coordination of care, someone that discovers problems and potential problems, support in a long term strong relationship and the case managers’ ability to work in close collaboration with primary care. Further investigations about the process and delivery of the intervention are needed in the future to determine the efficacy of the intervention. Also long-term follow-ups are needed since 12 months may be too short to see effects on for HRQoL. (Less)
Abstract (Swedish)
Popular Abstract in Swedish

Dagens vårdsystem står inför många stora utmaningar. Många av dem är relaterade till komplexa vårdbehov hos den allt större andelen sköra äldre personer. Denna andel ökar samtidigt som många vårdorganisationer har krav på sig att minska kostnaderna. Dessa äldre personer har ofta flera sjukdomar samtidigt och de har vanligtvis kontakter med många olika vårdgivare, på flera olika nivåer, samtidigt. Dessutom så står en liten grupp för en stor del av den totala vårdkonsumtionen. Fysiskt beroende och antalet sjukdomar ökar med ökad ålder. Detta tillsammans med att olika symptom – till exempel hörselproblem och minnesproblem – ökar, medför att många äldre personer kan ha svårt att hantera en situation... (More)
Popular Abstract in Swedish

Dagens vårdsystem står inför många stora utmaningar. Många av dem är relaterade till komplexa vårdbehov hos den allt större andelen sköra äldre personer. Denna andel ökar samtidigt som många vårdorganisationer har krav på sig att minska kostnaderna. Dessa äldre personer har ofta flera sjukdomar samtidigt och de har vanligtvis kontakter med många olika vårdgivare, på flera olika nivåer, samtidigt. Dessutom så står en liten grupp för en stor del av den totala vårdkonsumtionen. Fysiskt beroende och antalet sjukdomar ökar med ökad ålder. Detta tillsammans med att olika symptom – till exempel hörselproblem och minnesproblem – ökar, medför att många äldre personer kan ha svårt att hantera en situation som involverar många vårdgivare. Det är dessutom en stor risk att deras vård och omsorg blir splittrad, vilket kan leda till en sämre och osäkrare vård.



Det är viktigt att vårdsystemet är koordinerat och att det finns en kommunikation mellan olika vårdgivare. Det är också viktigt att det finns förebyggande insatser för att förbättra situationen för de äldre personerna. En modell som kan användas inom vård och omsorg är ”case management”. Det finns ingen bra översättning till svenska. Det finns inte heller någon enhetlig definition av case management, men många är eniga om att det handlar om en process som går ut på att en person bedömer/utvärderar, planerar, åtgärdar, utför åtgärderna, gör en ny bedömning, koordinerar olika insatser, och för personens talan för att kunna möta individens, och dennes familjs, hela vårdbehov.



Det finns en hel del studier som har undersökt effekterna av case management för sköra äldre, men med motstridiga resultat. Det finns studier som har visat att case management kan sänka vårdkonsumtion och öka hälsorelaterad livskvalitet och det finns de som inte kunnat hitta några sådana effekter. En del i förklaringen till att studierna gett så olika resultat kan ligga i komplexiteten i case management modellen där olika insatser inverkar individuellt eller tillsammans. En annan sak som gör det svårt att jämföra olika case management studier är att studierna utförts i olika länder och att miljön och vårdsystemet spelar stor roll. Många studier ger dessutom mycket knapphändig information om vad case management interventionen har innehållit och hur den utförts.



Hittills har case management för sköra äldre inte testats i någon större utsträckning i Sverige. Det finns således ett behov att prova och utvärdera case management, i det svenska vårdsystemet. Utvärderingen bör göras både med avseende på vårdutnyttjande och på kostnader, men även hur detta påverkar individen, med effekter på hälsorelaterad livskvalitet och upplevelser av interventionen.



Avhandlingen består av fyra delstudier med huvudsyftet att undersöka vårdkonsumtionsmönster och effekterna av en case management intervention för sköra äldre, med avseende på vårdutnyttjande och kostnader i relation till nytta. Vidare var syftet även att undersöka erfarenheter av interventionen, både från de sköra äldres perspektiv, men också från de som utfört interventionen, case managernas, perspektiv.



Den första delstudien var en kvantitativ studie som syftade till att undersöka vårdkonsumtionsmönster i termer av sjukhusvistelser och vårddagar över en sexårsperiod hos personer (60 år och äldre) och hur detta påverkas av nedsatt fysisk funktionsförmåga och risk för depression. Syftet var också att identifiera prediktorer för vårdkonsumtion. Studien baserades på ett material från ett av de fyra studieområdena i det nationella forskningsprojektet Swedish National Study on Aging and Care (SNAC). SNAC är en långsiktig nationell studie av åldrandet samt vården och omsorgen för äldre. Detta material omfattade 10 stycken ålderskohorter mellan 60 och 96 år, totalt 1402 individer. Baslinjedata samlades in mellan 2001 och 2003 och data angående antal vårdtillfällen på sjukhus och antal vårddagar på sjukhus samlades in från ett patientregister för de följande sex åren. De som inkluderats delades upp på två par av grupper. Dels de som klassificerats som beroende eller oberoende i fysisk funktionsförmåga (Aktiviteter i dagligt liv, ADL), och dels om de var i risk för/inte risk för depression.



Studien visade att alla fyra grupper hade ökning av sjukhusvistelser och vårddagar över sexårsperioden där särskilt det sjätte året, men även till viss del det femte året, hade högre värden än övriga år. Ökningen var dock större hos de som var beroende i ADL eller i risk för depression. De som var beroende i ADL hade också fler vårdtillfällen än de som var oberoende i ADL. Samma sak sågs för de som var i risk för depression jämfört med de som inte var i risk, men där var skillnaderna inte lika tydliga. Det var bara ålder som kunde förutsäga vårdtillfällen på sjukhus och vårddagar på sjukhus. Det fanns ett antal variabler som predikterade antingen sjukhusvistelser och/eller vårddagar för en eller flera av tidsperioderna. Mönstret som kunde urskiljas var att tidigare sjuhusvistelser och besvär med olika symptom predicerade vårdutnyttjande för 5-6 år efter baslinjen, medan olika diagnoser, och fysisk påverkan predicerade vårdutnyttjandet 1-2 år och 3-4 år efter baslinjemätningen. Detta betyder att det verkar vara svårt att förutsäga framtida vård. Den visar också att det är en mängd olika variabler som verkar spelar roll för framtida vårdbehov, däribland fysisk funktionsförmåga och risken för depression.



Den andra och tredje delstudien var delar i en randomiserad kontrollerad studie och ägde rum i en kommun i Sydsverige. Syftena i dessa studier var att undersöka effekterna av en case management intervention för sköra äldre med avseende på vårdutnyttjande och kostnader i relation till nytta. I dessa studier så lottades 153 äldre personer antingen till en kontrollgrupp (totalt 73 stycken) eller till en interventionsgrupp (totalt 80 stycken) som fick case managament. För att kunna bli inkluderad skulle man vara 65 år eller äldre, bo i ett eget hem i den aktuella kommunen (dvs. inte bo på särskilt boende, gruppboende etc.), man skulle ha hjälp med minst två aktiviteter i dagligt liv, och man skulle ha vistats på sjukhus minst två gånger, eller besökt läkare minst fyra gånger det senaste året.



Case management interventionen bestod av fyra delar: 1) ”traditionell” case management (som till exempel att utvärdera, skapa vårdplaner, koordinera); 2) ge allmän information (om till exempel om kommunens olika aktiviteter, säkerhet i hemmet och fysisk aktivitet); 3) ge specifik information anpassat till personens specifika behov (till exempel att ge information om personens specifika sjukdomar eller läkemedel); och 4) säkerhet och tillgänglighet (att vara kontakatbar via mobiltelefon under kontorstid måndag till fredag). Sjuksköterskor och sjukgymnaster jobbade som case managers och gjorde hembesök till alla i interventionsgruppen minst en gång i månaden under ett år.



Information gällande öppenvård (t.ex. kontakter med läkare och andra professioner, och akutmottagningsbesök) och slutenvård (vårdtillfällen på sjukhus och vårddagar på sjukhus) och hämtades från olika patientregister. Dessa data inhämtades för året innan personerna inkluderades i studien och för hela det år som studien pågick. Utöver detta samlades det in data genom strukturerade intervjuer som genomfördes vid baslinje, och därefter vid 3-, 6-, 9- och 12 månader efter baslinjemätningen. Dessa data inkluderade enskilda frågor och olika standardiserade frågeinstrument.



Studierna visade att interventionsgruppen hade lägre andel akutmottagningsbesök som inte ledde till sjukhusinläggning, 6-12 månader efter baslinjemätningen. Detta gällde både i medeltal (0.08 besök i interventionsgruppen mot 0.37 i kontrollgruppen) samt andelen (16.7 mot 46.9% i respektive grupp). Vilket innebär att de som var i kontrollgruppen blev hemskickade från akutmottagningen i större utsträckning än de i interventionsgruppen. Interventionsgruppen hade också för denna period (6-12 månade efter baslinjemätningen) längre andel besök hos läkare i öppenvården, jämfört med kontrollgruppen (4.09 mot 5.29). Inga skillnader hittades för antalet vårdtillfällen på sjukhus, vårddagar på sjukhus eller omfattningen av hemstjänst eller hemsjukvård under interventionsåret. När man tittade på hela studieåret hade däremot interventionsgruppen även mindre hjälp från informella vårdgivare jämfört med kontrollgruppen, både vad gäller antalet timmars hjälp med instrumentell ADL (s.k. IADL som innebär t.ex. städning, transport och matlagning), med 200 mot 333 timmar, och kostnader, SEK 34 186 mot SEK 57 020 (motsvaras ungefär av €3927 mot €6550). Inga skillnader fanns dock med avseende på totala kostnader för studieåret, och inte heller för skillnader i hälsorelaterad livskvalitet.



Den fjärde delstudien var en intervjustudie med syftet att belysa deltagarnas och case managernas erfarenheter av interventionen. Total intervjuades 14 deltagare som fått case management om sina upplevelser och erfarenheter. Dessutom intervjuades sex stycken case managers om totalt 15 stycken deltagare som de träffat i case managementstudien. Totalt 29 intervjuer togs med i analysen där de analyserades med innehållsanalys. Resultatet visade att case management interventonen kunde tolkas utifrån två områden, att ge/ta emot som en vårdmodell, och att jobba som/interagera med en case manager. Resultatet bestod av totalt fyra kategorier: 1) case management som att gå in i en ny yrkesroll; 2) case managern som en coachande bevakare, båda sett från case managerns synvinkel; och 3) case management som en möjlig ytterligare resurs; och 4) case managern som en hjälpande hand, sett från deltagarens synvinkel. Varje kategori innehåll olika subkategorier som alla speglade innehållet i respektive kategori.



Sammanfattningsvis så visade resultaten på att gruppen av äldre är väldigt heterogen, dvs. att det finns stora olikheter mellan olika individer, även bland de som betecknas som sköra. Detta kan vara en av anledningarna till att det var så svårt att hitta universella prediktorer för vårdutnyttjande. Det verkar som om case management är effektivt genom att minska antalet läkarbesök i öppenvården, minska omfattningen av anhörigas insatser och genom att färre i interventionsgruppen blev hemskickade när de besökte akutmottagningen. Interventionen var dessutom kostnadsneutral. Viktiga delar i case management som kan ha bidragit till detta är att kontakten med case managern gav en ökad kontinuitet och samordning av vården, att någon hade möjlighet att upptäcka potentiella och aktuella problem och att åtgärda dessa. Case managern kunde också ge olika former av stöd och bygga en relation baserad på förtroende. En annan viktig aspekt kan vara case managerns möjlighet att samarbeta med primärvården.



I framtida forskning av case management för denna grupp behövs en processutvärdering av interventionen för att undersöka i vilken utsträckning olika delar har utförts för att bättre kunna avgöra om interventionen och dess olika delar är effektiv. Det behövs också en längre uppföljningstid än 12 månader då detta kan vara för kort tid för att kunna se effekter för t.ex. hälsorelaterad livskvalitet. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Erhrenberg, Anna, Dalarna University
organization
publishing date
type
Thesis
publication status
published
subject
keywords
Intervention Studies, Hospitalisation, Informal Caregiver, Case Management, Content Analysis, Registries, Healthcare Utilisation, Frail Elderly, Complex intervention, Healthcare Costs
in
Lund University Faculty of Medicine Doctoral Dissertation Series
volume
2013:97
pages
231 pages
publisher
Lund University: Faculty of Medicine
defense location
SSSH-salen, Health Science Center, Baravägen 3 Lund
defense date
2013-09-26 09:00:00
ISSN
1652-8220
ISBN
978-91-87449-69-7
language
English
LU publication?
yes
id
5711eda0-2a8a-4e50-b467-98449186e01c (old id 3972081)
date added to LUP
2016-04-01 13:53:54
date last changed
2019-11-19 13:49:05
@phdthesis{5711eda0-2a8a-4e50-b467-98449186e01c,
  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.<br/><br>
<br/><br>
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 the case managers’ experiences of the intervention.<br/><br>
<br/><br>
Study I was a quantitative study comprising ten age cohorts aged between 60 and 96 years (n=1402) drawn from the Swedish National Study on Aging and Care (SNAC). Baseline data were collected between 2001 and 2003 and data on number and length of hospital stays were collected for the six years after the baseline year. The sample was divided into two pairs of groups; those who were dependent/independent in activities of daily living (ADL), and those at risk/not at risk of depression. The six years period of healthcare utilisation was also divided into utilisation 1-2, 3-4, and 5-6 years after baseline. Studies II and III had an experimental design where 153 people were consecutively and randomly allocated to either a control group (n=73) or a group that received a case management intervention (n=80). Included were those aged 65+ years who lived in their ordinary homes, were dependent in two or more ADL, and had had at least two hospital stays, or four physician visits, in the previous year. Data concerning inpatient (hospital stays and length of stay) and outpatient healthcare utilisation (contacts with physician or other healthcare professionals, and emergency department visits) (Study II) and costs (Study III) for the year before baseline and for the one year study 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 intervention in Studies II and III, and six case managers who had performed the intervention. The case managers were interviewed about a total of 15 different participants, whom they had met in the intervention. The interviews were analysed with content analysis.<br/><br>
<br/><br>
Study I revealed a significant increase in hospital stays in all groups over time. ADL-dependent persons and those at risk of depression had significantly more hospital stays, except for those at/not at risk of depression in years 2, 4 and 5. Main predictors for healthcare utilisation 5-6 years after baseline were age, previous healthcare utilisation and various symptoms; and at 1-2 and 3-4 years after baseline, age, various diagnostic groups and various physical variables. Thus healthcare utilisation patterns seem to be similar for the different groups over the six years, but it is difficult to find universal predictors.<br/><br>
<br/><br>
In Studies II and III there were no differences between the interventions and control groups were found at baseline (in demographics, baseline characteristics, in or outpatient healthcare utilisation, utilisation in informal care, municipal home care, municipal home services or costs). The results showed that, compared to the control group, the intervention group had significantly lower mean number and proportion of emergency department visits not leading to hospitalisation 6-12 months after baseline (0.08 vs. 0.37, p=0.041 and 16.7 vs. 46.9%, p=0.012, respectively). The intervention group also had a significantly lower mean number of visits to physicians in outpatient care 6-12 months after baseline (4.09 vs. 5.29, p=0.047). The intervention group had significantly less help with self-reported informal care in terms of provided hours and cost for help with Instrumental ADL (IADL) during the one-year study (200 vs. 333 hours per year, p=0.037; €3927 vs. €6550, p=0.037). There were no significant differences between the intervention group and control group in terms of total cost of the one-year study, or QALY.<br/><br>
<br/><br>
Study IV showed that the experience of the case management intervention could be interpreted according to 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. Each category constituted different subcategories, all reflecting aspects of the respective category.<br/><br>
<br/><br>
The results indicate that the population of older people are heterogeneous which may be one reason for the difficulties to find universal predictors for healthcare utilisation. This may also be the reason for the lack of effects on hospital stays, length of stay, and HRQoL in the case management studies. However, the case management intervention appears to have effects in emergency department visits not leading to hospitalisation, visits to physician in outpatient care, in informal care, and is cost neutral. This indicates that the case management intervention seems to have impact on the situation; not only for the older person, but also their informal caregivers. Possible features of the case management intervention that may explain these effects may be interpersonal continuity, coordination of care, someone that discovers problems and potential problems, support in a long term strong relationship and the case managers’ ability to work in close collaboration with primary care. Further investigations about the process and delivery of the intervention are needed in the future to determine the efficacy of the intervention. Also long-term follow-ups are needed since 12 months may be too short to see effects on for HRQoL.}},
  author       = {{Sandberg, Magnus}},
  isbn         = {{978-91-87449-69-7}},
  issn         = {{1652-8220}},
  keywords     = {{Intervention Studies; Hospitalisation; Informal Caregiver; Case Management; Content Analysis; Registries; Healthcare Utilisation; Frail Elderly; Complex intervention; Healthcare Costs}},
  language     = {{eng}},
  publisher    = {{Lund University: Faculty of Medicine}},
  school       = {{Lund University}},
  series       = {{Lund University Faculty of Medicine Doctoral Dissertation Series}},
  title        = {{Case management for frail older people. Effects on healthcare utilisation, cost in relation to utility, and experiences of the intervention}},
  url          = {{https://lup.lub.lu.se/search/files/3653171/4017575.pdf}},
  volume       = {{2013:97}},
  year         = {{2013}},
}