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Case management for frail older people – a qualitative study of receivers’ and providers’ experiences of a complex intervention
© Sandberg et al.; licensee BioMed Central Ltd. 2014
Received: 2 July 2013
Accepted: 7 January 2014
Published: 10 January 2014
Case management interventions have been widely used in the care of frail older people. Such interventions often contain components that may act both independently of each other and interdependently, which makes them complex and challenging to evaluate. Qualitative research is needed for complex interventions to explore barriers and facilitators, and to understand the intervention’s components. The objective of this study was to explore frail older people's and case managers’ experiences of a complex case management intervention.
The study had a qualitative explorative design and interviews with participants (age 75-95 years), who had received the case management intervention and six case managers who had performed the intervention were conducted. The data were subjected to content analysis.
The analysis gave two content areas: providing/receiving case management as a model and working as, or interacting with, a case manager as a professional. The results constituted four categories: (1 and 2) case management as entering a new professional role and the case manager as a coaching guard, as seen from the provider’s perspective; and (3 and 4) case management as a possible additional resource and the case manager as a helping hand, as seen from the receiver’s perspective.
The new professional role could be experienced as both challenging and as a barrier. Continuous professional support is seemingly needed for implementation. Mutual confidence and the participants experiencing trust, continuity and security were important elements and an important prerequisite for the case manager to perform the intervention. It was obvious that some older persons had unfulfilled needs that the ordinary health system was unable to meet. The case manager was seemingly able to fulfil some of these needs and was experienced as a valuable complement to the existing health system.
Complex interventions are challenging to evaluate since they contain components that may act both independently of each other and interdependently, which makes it complicated to assess individual aspects of the intervention. The challenges are, among others, related to difficulties in standardising the study design and delivery of the intervention, and assessing the impact of local contextual factors . The British Medical Research Council (MRC)  has developed a research framework for complex interventions. They suggest a multi-step approach, including a development phase, followed by feasibility/piloting, evaluation (preferably through a randomised controlled trial) and implementation. They conclude that evaluation of complex interventions requires a mix of both quantitative and qualitative methods to get a more comprehensive understanding of the interventions. One challenge in complex interventions is the length and complexity of causal chains linking the intervention with outcome . This means that the intervention may affect important factors that were not planned for and not measured with quantitative methods , factors that could be discovered with qualitative methods. Thus, knowledge from qualitative research of a complex intervention is crucial to fully interpret the results of and understand an intervention.
Case management is a complex intervention that has been used in different health care settings such as psychiatry and geriatric care [2, 3]. It has no single definition but it has been suggested that basic case management may include identification and outreach, comprehensive individual-based assessment, care planning, care coordination, service provision, monitoring, evaluation and meeting individual needs [4, 5]. Several studies have investigated the effects of case management for older people. These studies mainly focused on outcomes such as healthcare utilization and costs, quality of life, physical or cognitive functioning, quality of care and patient satisfaction . The reported effects are contradictory . In addition, such studies are seldom described in detail , which makes it difficult to compare them. Thus, there is a need for in-depth investigations to gain deeper understanding of the interventions, which will allow comparisons to be made and will enable us to draw conclusions about best practices . To be able to further develop case management interventions a greater understanding of the intervention’s content and construction is needed. Qualitative studies are important to identify different barriers and facilitators that could be underlying reasons for an intervention being successful or not  and are necessary for implementation . A qualitative evaluation is necessary to obtain a comprehensive description of the intervention’s components, to explore conditions for implementation, to establish construct validity and to facilitate possible replication . Furthermore, it is essential to investigate different perspectives of the experience of an intervention, from both those receiving and those performing the intervention. However, studies of these different perspectives are generally lacking.
Some qualitative studies have focused on experiences of case management for older people [11–13]. The studies by JM Nelson and P Arnold-Powers  and K Brown, K Stainer, J Stewart, R Clacy and S Parker  found that the relationship between the case managers (CM) and participants was highly valued. JM Nelson and P Arnold-Powers  reported that the relationship with CM helped to provide security, safety and comfort for clients, and K Brown, K Stainer, J Stewart, R Clacy and S Parker  reported that their participants experienced that the CM had improved their quality of life. P Sargent, S Pickard, R Sheaff and R Boaden  and  also found that the participants were satisfied with the CMs’ different skills and ability to arrange services. According to P Sargent, S Pickard, R Sheaff and R Boaden  psychosocial support was emphasised by both the patients and carers with experience of case management, and was viewed as being equally important as clinical care. Complex interventions are dependent on the local context , which means that case management interventions could be experienced in various ways and have unique problems depending on the context they are performed in. Thus, each intervention needs to be explored in terms of what has been done and also how it was experienced, from both the providers’ and the receivers’ perspectives.
The aim was to explore older people's and case managers’ (CM) experiences of a complex case management intervention.
The study had a qualitative design, using opened-ended interviews with older people who were part of a case management intervention and the CMs who had performed the intervention.
Characteristics of the interviewed receivers and providers of the intervention
The interview was made after…
Participant receiving home care services
Widow, living apart from a new man
Profession of the CM
Code of the participant
Gender of the participant
Participant receiving home care services
CM1 - Nurse
CM2 - Nurse
CM2 - Nurse
CM3 - Nurse
CM3 - Nurse
CM4 - Nurse
CM4 - Nurse
CM5 - Physiotherapist
CM5 - Physiotherapist
CM5 - Physiotherapist
CM5 - Physiotherapist
CM6 - Physiotherapist
CM6 - Physiotherapist
CM6 - Physiotherapist
CM6 - Physiotherapist
Interviews were also conducted with the CMs. Six CMs were interviewed, two of whom had been educated as physiotherapists and four as nurses. The CMs were, depending on the number of participants, employed on a part-time basis in the research project. They were all recruited from municipal, primary care or hospital settings. The CMs were interviewed about every individual that they had met. In total, 162 interviews were made. Purposeful selection of fifteen interviews was used to obtain variation in CMs, gender, age and use of home care services. The CMs worked in the research project for between 2 and 5 years and had experience of caring for or rehablitating older people (Table 1).
The case management intervention was in addition to standard care and the participants were consecutively recruited between 2006 and 2011. The intervention, conducted in the southern Sweden, was a one-year home-based case management intervention with home visits at least once a month . The intervention comprised four components: traditional case management (including assessment, care planning, follow-up, care coordination, home visits, telephone calls and advocacy), general information (about the healthcare system, social activities, nutrition and exercise, among other things), specific information (related to the respondent’s specific health status, individual needs and medication) and safety and continuity (availability of CM by cell phone during working hours) .
The CM study was developed according to the MRC’s framework for complex interventions . The pilot study phase, in which the intervention was developed, is described elsewhere . Changes after the pilot study have also been reported .
Data were collected by means of personal interviews. The interviews were conducted between 2007 and 2012, and were conducted by four different persons due to a change in staff during this period. The first author (M.S.), the fourth author (J.K.), and two research assistants (one male and one female) conducted eleven, eight, eight and two interviews, respectively. The interviews were semi-structured, which meant that they were neither fully structured nor fully unstructured. The participants were free to talk about any subject, but the interviewer guided the interview . Two thematic interview guides were used – one for the participants and one for the CMs – to ensure that the interviews covered the same areas of content. The CM interviews covered two themes: (1) the person they met and how the contact started, what they had done and what effects they thought this might have had; and (2) how they perceived the intervention, whether there was something that they considered successful or unsuccessful. The interview guide for the participants did not only comprise questions about the intervention: as well as questions on “help and support” (including questions about the CM and the case management intervention), it also covered “health”, “contacts with the healthcare system” and “the future and concerns”. Open questions were used and included questions such as “could you tell me about an ordinary meeting with the case manager?” (to the participant) and “could you tell me about this person that you have met in your role as case manager?” (to the case manager). Probing questions could for instance be “could you give an example?”, “how did that feel?” and “What did you do then?”. The interview guides were changed slightly during the study meaning that the order of the questions where changed, and thus all interviews covered the same areas. All interview guides were tested in pilot interviews on both the participants and CMs. No major changes were made in the interview guides after the pilot interviews and thus included in the study. Each interview started with clarification of the aim of the interview and the interviewee’s right to terminate the interview whenever he/she wanted.
The interviews with participants were conducted after they had received the intervention for at least nine months in order that they had undergone the majority of the intervention. They were interviewed after a mean of 14 months after they were included in the CM intervention. The interviews were carried out in a place chosen by the participant. All interviews took place in the participants’ homes and were between 40 minutes and 2 hours 51 minutes long. During the interviews, no-one besides the participant and the interviewer was present. However, in one interview the sister was in an adjacent room and the participant asked her some questions.
Interviews with the CM were made for each participant they had met after the participant had received the intervention for at least nine months. The CM interviews were conducted after in mean 17 months after the participant had been included in the intervention study. The CMs had with them the case records of their participants. All CM interviews took place at the department of the researchers and lasted between 9 and 24 minutes. All interviews were audio recorded and transcribed verbatim.
Examples of the analysis process
He had not really the insight that there was something seriously… but he just laughed it off when you talked about it.
A failure to reach
Dealing with barriers
ENTERING A NEW PROFESSIONAL ROLE
We talked about it… about residential care for her. And if it… tried… well, talk a bit about what it was like to have some people around and so. But she… no. She did not want to. She did not want much at all [laughs a bit].
Meeting people that do not want to be helped or do not want to incommode
You become despondent when you do not succeed. But … but I have offered it anyway. It sure is tough, so, it is.
To feel personal involvement
Yes we're talking about everything … I think. I do not remember anything exactly… but we have… we are talking about everything. Yes it is just as if we have become friends. I see it as if she has become my friend (pause).
To feel confident in a person and her competence
A POSSIBLE ADDITIONAL0020RESOURCE
And it's never in a hurry either, but they… There was never any hurry. Never ever. And they were helpful.
To get a chance to build a stable relationship
Well you, that (pause) that I have not needed to search for [health care] because all I have needed… uh to ask for uh I have uh used the case manager for that…
To find a replacer for the usual health system
Gaining a safety net
This study was approved by the Regional Ethical Review Board in Lund (Ref. nos. 342/2006 and 499/2008) and is registered at Clinicaltrails.gov (Ref. No NCT01829594). All participants provided written informed consent for participating. The participants’ autonomy was acknowledged by emphasising, both before and at the beginning of the interview, that participation was voluntarily, and that the participant could withdraw from the study at any stage. They also were also informed that confidentiality should be maintained when presenting the results.
Main categories and categories
The provider’s perspective
The participant’s perspective
The case manager as…
A coaching guard
A helping hand
• The solver
• The one who has information
• The supporter
• The one who supports
• The standing guard
• The one who keeps an eye on things
• The navigator
• The one who knows what to do or where to turn
Case management as…
Entering a new professional role
A possible additional resource
• Dealing with barriers
• Something unknown
• Building trust
• Reliable competence
• Setting limits
• Limited resource
• Making a possible difference
• Gaining a safety net
The provider’s perspective
The case manager as a coaching guard
One category concerned the providers’ view of themselves as coaching guards in their roles as CMs. This implied functioning as someone who solved problems, someone who supported the participant and helped them when something happened, as well as helping the participant to navigate through the health system in terms of contacting and interacting with various caregivers. It also implied being a guard that could take control if the situation required it. The category covered four different subcategories: “The solver”, “The supporter”, “The standing guard” and “The navigator”.
Last time we were there he again had much swelling in … yes, his feet, and we said that he should probably contact a doctor immediately because of this. And they had actually done this and had been at the primary care center with … a doctor, and the neighbor had … driven him because his daughter was on holiday. And he had had some changes to his diuretic medication and, um (pause), his feet looked much better the last time we were there … (N0114)
She … had a very strong need to talk about her situation … so the first few times it was enough to just sit and talk with her. (P0095)
The standing guard
And so I tried to emphasise to the [physician] that it was not just that she was dizzy, but that she actually fell. It would sooner or later end badly. (P0081)
R: (…) his wife had to help him up five or six times a night and then there was nothing – yes there was a crisis there for a while …
I: And what did you do about it?
R: I contacted the occupational therapist and physiotherapist so that he got help with it, and so that he got this period of relief (P0098)
Case management as entering a new professional role
This category covered four subcategories: “Dealing with barriers”, “Building trust”, “Setting limits” and “Making a possible difference”. It was obvious that when the CM narrated about their experiences of case management it was in the light of working in new ways. The new role entailed both possibilities and barriers. The barriers included sometimes failing to reach the participant and therefore failing to help them or to perform the intervention. The possibilities concerned building stable and good relationships with the participants and the intervention enabling them to make a difference in terms of helping people. To work with a model that sometimes included strong relationships could also be challenging as the CMs sometimes felt personally involved and therefore had to define and set limits for the relationships.
Dealing with barriers
He … did not want to let me in, but instead said: “Yes, you can come when you have arranged these things.” But they were things I couldn’t help to arrange. (N0055)
(…) and it is clear that she could have got more help but … but she really wanted to struggle on herself. This business of dressing as well … It would certainly have been much easier if you dressed her, instead of sitting for twenty to thirty minutes every morning. But she really wanted to do it. (P0095)
Yes, after the first meeting, after the first few minutes in fact, it felt so right. Partly because R [the participant] is a very open person who can talk about their life quite openly. Yes, our first contact was actually very good, and it still feels really good. … Our contact has been very positive (N0004)
Well, then I felt a bit guilty because I could easily have done it [gone to the bank with the participant’s money when she was hospitalised]. But you can’t get too involved as it becomes hard to say no. And she puts all her trust in me. (N0004)
Making a possible difference
I: But did you feel that she benefited from what you did for her?
R: Yes, the pain diary [shows], above all, that she had less pain. That was great. And she took her medications more regularly (P0169)
The receiver’s perspective
The case manager as a helping hand
From the participant’s perspective the contact with the CM was very much about receiving a helping hand. A helping hand that could hold them tight when they needed it, lead them through difficulties and pointing out the direction when they were confused. A helping hand could also be supportive when they felt they were losing control. The category covered four subcategories: “The one who has information”, “The one who supports”, “The one who keeps an eye on things” and “The one who knows what to do or where to turn”. These categories are closely linked to each other as, for example, someone who knows where to turn is also someone who has information.
The one who has information
I: (…) have they [the case managers] made a difference for you, do you think?
R: Yes, a little bit … anyway. Because… you can ask about things. If there is anything you need to know, they can give you the answer. (R0083)
The one who supports
Yes, they tried to persuade me to be X-rayed and to think about surgery. Tried to persuade me to … do the things that I tend to put off. I always put things off, there is so much to choose from so I … put it off and it doesn’t get done. (R0091)
The one who keeps an eye on things
Because she looked at that [leg] every time she came, because you know it’s still not quite right, because it’s still swollen and a bit red. But she said that it’s … the warfarin. (R0025)
The one who knows what to do or where to turn
And I find it very difficult to keep my balance. And they [name, physiotherapist in the project] asked me how would it be if you stood with your legs further apart … then your balance will be a bit better … And I’ve been doing it, and it’s absolutely true, because now I can stand and wash up … (R0079)
Case management as a possible additional resource
For the participants, case management was something new. Initially, they did not know exactly what to expect or what they could use the resource for. In most cases, the participants eventually realised that case management included a competence that one could depend on. In some cases, a strong relationship was built and case management was experienced as something beneficial and something that could contribute to a sense of security. The participants knew that the case management was a limited resource, in terms of both in intensity and time. But they experienced case management as a resource that sometimes replaced usual care, and a resource not only for practical matters, but also emotional ones. The category comprised four subcategories: “Something unknown” “Reliable competence”, “Limited resource” and “Gaining a safety net”.
I: Has this meant anything to you? Has it been important [R interrupts]
R: I didn’t really know what it meant, but it’s clear that uh … she was like (mumbles a little) some support anyway, after all (pause) (R0029)
And you could talk to her … about everything. About things I do not want to mention to you. But I developed very good trust in her… (R0143)
R: (…) I miss her when she doesn’t come.
I: You’ve missed it?
R: Yes, it was a bit tough … a very sweet person I must say… (R0012)
Gaining a safety net
I feel secure … just knowing she will come, now I have the time she will come, now I think it might be the nineteenth of … May she will come, no the nineteenth of June, I looked at the calendar the other day and you have put a mark in it. Just knowing she will come makes me feel secure. (R0031)
Discussion of the results
There is a need to investigate the ‘black box’ of complex interventions and this study was important to be able to understand some of the essential components in this case management invention. The knowledge we have gained could contribute to understanding of the possibilities and challenges in complex case management interventions and implementation.
It was obvious that trust and confidence were crucial facilitators for performing the intervention and they permeated various categories. It is known that trust and confidence are important factors for building and maintaining a solid relationship between patients and caregivers [23–25] and are particularly important for older people with repeated health care contacts. A good relationship has been reported to improve health outcomes , as well as perceived effectiveness of care and self-reported health . In addition, previous case management studies showed that the CM-client relationship is important for enabling the CM to provide help . Interpersonal continuity and patient/person-centred care have been suggested to be important factors for establishing a strong relationship [23, 28]. This is, however, not always achieved in the regular health system [29–31]. It is possible that the person-centred approach and regular visits/repeated contacts were two facilitators that contributed to the solid CM-client relationship in this intervention. The findings suggest that the case management intervention may compensate for shortcomings in the existing system in terms of being more person-centred and thus encouraging a strong trusting relationship. Client-centeredness is also one component that has been stated to be one of the theoretical components of case management  and positive effects on client/patient-centeredness have also been found in a previous review investigating case management in primary care .
Another important finding was the CMs’ ability to meet participants’ unmet service needs. “The solver”, “The standing guard” and “The one who keeps an eye on things” were important categories contributing to this result. The improvement in identifying unmet service needs through case management was reported in a review by EC You, D Dunt, C Doyle and A Hsueh  and in a Canadian study by R Hebert, M Raiche, MF Dubois, NR Gueye, N Dubuc and M Tousignant . The ability to meet unmet needs and to react if anything happens also contributed to feelings of security among the participants in this study. This is in line with other studies that reported that both clients and CMs felt that the ability to detect health-related changes in the receivers’ conditions contribute to a feeling of security [11, 13, 35]. The feeling of security reported in this study stands in contrast to insecurity that dependent older people may experience in the ordinary health system due to reduced autonomy, limited possibilities for negotiation  or fear that they will get abandoned by the carer and not receive any care if they criticise the care [37, 38]. Thus, the CMs’ ability to help and solve problems and give support when needed seems to be a fundamental CM function in this study. This function was also important for the participants as it contributed to a feeling of security, which is highly desirable in healthcare as it a prerequisite for successful care.
The challenges the CMs met in terms of undergoing a transition from a familiar profession to a CM role was another important finding in the present study. This was seen when the CMs felt too personally involved and had to set limits. This may be a result of the flexibility within their role as CMs which allowed them to be creative and find individual solutions for the participants. This flexibility and free role could also be problematic. The lack of role definition has been identified as a key barrier to the success of case management for older people . Thus, flexibility may be a facilitator for finding individual solutions for the clients, but may at the same time be a barrier in terms of making the role unclear. It was obvious that the CM underwent a transition to deal with this new way of working. This process could be difficult and could make the CMs vulnerable and subject to various kinds of stressors . It is therefore important to give the CMs solid support to deal with the professional transition and thus the difficulties setting limits . One form of support could be mentorship/supervision . When implementing case management the CMs should also receive training in a multidisciplinary collaboration [35, 41]. This could increase awareness of the CMs by other practitioners in the health system, which is important to be able to improve the outcomes of the role . Thus, when implementing a case management intervention, efforts should be made to support the CM and to acknowledge the case management function in the existing health system.
Qualitative studies can be assessed through the concept of trustworthiness, which comprises credibility, transferability, dependability and conformability . Credibility refers to the believability of the data and whether the findings are faithfully based on the descriptions provided by the participants . To deal with potential threats to credibility, data from both older persons and CMs were used. To increase credibility, efforts to achieve variation were made (Table 1). One potential threat to credibility was the length and, thus, depth of the interviews. However, the CMs knew the aim of the interview and what they were supposed to talk about, which made the interviews very focused. In the interviews with the participants, only a small part of the interview was about the experiences of the intervention, which may also have influenced the depth. In qualitative research, the sample size should be based on the information needs . The concept of data saturation – sampling until no new information is obtained and redundancy is achieved – is widely used. No new subcategories emerged when analysing the final ten interviews, which allowed us to conclude that saturation was reached DF Polit and CT Beck . Dependability refers to whether the interpretations are representative and whether the data are stable over time . To strengthen dependability, the interviews were carried out by different persons and thematic interview guides were used to make sure the interviews covered the same areas. Having different interviewers also strengthens the conformability, which relates to questions about the researches’ subjectivity. To reduce the risk of the results being influenced by the researches’ preunderstanding, investigator triangulation  was used. Concerning the transferability of the results, it is important to bear in mind that the local context may have influenced the findings.
The experiences of a case management intervention could be interpreted from the CM perspective as entering a new professional role and being a coaching guard for the older person. The older persons experienced the intervention as receiving a possible additional resource and the interaction with the CM as a helping hand. The new professional role could be experienced as both challenging and as a barrier. Continuous professional support is seemingly needed when implementing a case management intervention for older persons. Mutual confidence and the participants experiencing trust, continuity and security were important elements and an important prerequisite for the case manager to perform the intervention and make a difference. It was obvious that the some older persons had unfulfilled needs that the ordinary health system was unable to meet. The CM was seemingly able to fulfil some of these needs and was experienced as a valuable complement to the existing health system.
This project was carried out in collaboration between the Faculty of Medicine at Lund University, the Swedish Institute for Health Sciences (Vårdalinstitutet), Skåne University Hospital, primary in Eslöv and Eslöv municipality. We are grateful to the Faculty of Medicine at Lund University, Vårdalinstitutet, Region Skåne, Johan and Greta Koch’s Foundation, the Swedish Association of Health Professionals (Vårdförbundet), the Swedish Society of Nursing and Södra Sveriges Sjuksköterskehem (SSSH) for funding this study. We are also most grateful to the participants and their next of kin. We would especially like to thank the following people: Sara Modig, physician at Tåbelund Primary Care Centre; head nurse Magdalena Andersson of Eslöv municipality; and registered nurses Marie Louise Olofsson, Jeanette Hellberg, Lena Jönsson and Jenny Linderstål, and registered physiotherapists Caroline Larsson and Ulrika Olsson Möller, all of whom worked as CMs. We would also like to thank Stephen Gilliver for revising the English in this article and for translating the excerpts from the interviews.
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