Case management for integrated care of older people with frailty in community settings

Euan Sadler, Zarnie Khadjesari, Alexandra Ziemann, Katie J. Sheehan, Julie Whitney, Dan Wilson, Ioannis Bakolis, Nick Sevdalis, Jane Sandall, Tayana Soukup, Teresa Corbett, Daniela C. Gonçalves-Bradley, Dawn Marie Walker

Research output: Contribution to journalReview articlepeer-review

4 Citations (SciVal)

Abstract

Background: Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems. 

Objectives: To assess the effects of case management for integrated care of older people living with frailty compared with usual care. 

Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts. 

Selection criteria: We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty. 

Data collection and analysis: We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence. 

Main results: We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence)
• Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence)
• Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from −6.32 points (95% CI −11.04 to −1.59) to 6.1 points (95% CI −3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence)
• Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence)
• Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from −0.12 points (95% CI −0.93 to 0.68) to 3.4 points (95% CI −2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence). Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence)
• Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care. 

Authors' conclusions: We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.

Original languageEnglish
Article numberCD013088
Number of pages119
JournalCochrane Database of Systematic Reviews
Volume2023
Issue number5
DOIs
Publication statusPublished - 23 May 2023

Bibliographical note

Funding Information:
Cochrane EPOC supported the authors in the development of this review. The following people conducted the editorial process for this review. Sign-off Editor (final editorial decision): Terry Quinn, University of Glasgow; Co-ordinating Editor of Cochrane Dementia and Cognitive Improvement Managing Editor (selected peer reviewers, collated peer-reviewer comments, provided editorial comments/guidance to authors, edited the article): Lara Kahale and Joey Kwong, Cochrane Central Editorial Service Editorial Assistant (conducted editorial policy checks, collated peer-reviewer comments, supported editorial team): Leticia Rodrigues, Cochrane Central Editorial Service Copy Editor (copy editing and production): Julia Turner, c/o Cochrane Central Production Service Peer-reviewers (provided comments and recommended an editorial decision): Anne Hendry, University of the West of Scotland (clinical review) Catherine J Evans, King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation; and Sussex Community NHS Foundation Trust (clinical review) Matthew Maddocks, King's College London (clinical review) Catherine Hofstetter (consumer review) Nuala Livingstone, Cochrane Evidence Production and Methods Directorate (methods review) Valerie Wells, Cochrane Public Health MRC/CSO Social and Public Health Sciences Unit, University of Glasgow (search review) Sign-off Editor (final editorial decision): Terry Quinn, University of Glasgow; Co-ordinating Editor of Cochrane Dementia and Cognitive Improvement Managing Editor (selected peer reviewers, collated peer-reviewer comments, provided editorial comments/guidance to authors, edited the article): Lara Kahale and Joey Kwong, Cochrane Central Editorial Service Editorial Assistant (conducted editorial policy checks, collated peer-reviewer comments, supported editorial team): Leticia Rodrigues, Cochrane Central Editorial Service Copy Editor (copy editing and production): Julia Turner, c/o Cochrane Central Production Service Peer-reviewers (provided comments and recommended an editorial decision): Anne Hendry, University of the West of Scotland (clinical review) Catherine J Evans, King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation; and Sussex Community NHS Foundation Trust (clinical review) Matthew Maddocks, King's College London (clinical review) Catherine Hofstetter (consumer review) Nuala Livingstone, Cochrane Evidence Production and Methods Directorate (methods review) Valerie Wells, Cochrane Public Health MRC/CSO Social and Public Health Sciences Unit, University of Glasgow (search review) The authors also acknowledge Cochrane Effective Practice and Organisation of Care (EPOC), particularly the following members. Sasha Shepperd, for her support as Contact Editor for the protocol, and for providing comments on early drafts of the review Nia Roberts, Information Specialist, for conducting the updated searches for this review Sasha Shepperd, for her support as Contact Editor for the protocol, and for providing comments on early drafts of the review Nia Roberts, Information Specialist, for conducting the updated searches for this review For the purpose of open access, the review authors have applied a Creative Commons Attribution license (CC BY) to any Author Accepted Manuscript version arising from this submission.

Funding Information:
We acknowledge the support of the National Institute for Health and Care Research (NIHR), via Cochrane Infrastructure funding to the Effective Practice and Organisation of Care (EPOC) Group and NIHR Applied Research Collaboration (ARC) Wessex National Institute for Health Research (NIHR); King's Improvement Science, UK JS is an NIHR Senior Investigator, and NS and JS's research is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King's College Hospital NHS Foundation Trust.

Funding Information:
Funding: "grant from The Netherlands Organization for Health Research and Development (311040201) as part of the National Care for the Elderly Program” Ethical approval: "The institutional review board of the University Medical Center Utrecht approved the U-PROFIT trial (protocol ID 10–149/O), which is registered as NTR2288".

Funding Information:
Funding: "funded in part through a community property tax levy that generates over $13 million annually to finance care management and home care services, with support from the Robert Wood Johnson Foundation's Building Health Systems Initiative"

Funding Information:
Funding: Australian National Health and Medical Research Council Health Services Research Grant

Funding Information:
Funding: "Health Transition Fund (Health Canada); Canadian Institutes of Health Research; Canadian Health Services Research Foundation; Fonds de la recherche en santé du Québec (FRSQ); Quebec Ministry of Health and Social Services."

Publisher Copyright:
Copyright © 2023 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.

ASJC Scopus subject areas

  • Pharmacology (medical)

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