Case-managed care for community-dwelling frail elders

In a case management model, health professionals, often nurses, manage multiple aspects of patients’ long-term care (LTC), including status assessment, monitoring, advocacy, care planning, and linkage to services, as well as transmission of information to and between care providers. Case managers often care for frail elderly patients who live independently. Frail elderly patients often have complex health needs that require care from multiple providers, and are at increased risk of adverse outcomes from conditions that could be prevented with early detection and treatment (Eklund 2009*).

Expected Beneficial Outcomes (Rated)

  • Reduced nursing home use

  • Reduced hospital utilization

  • Improved day-to-day functioning

Other Potential Beneficial Outcomes

  • Improved health outcomes

  • Increased patient satisfaction

  • Increased caregiver satisfaction

  • Improved mental health

  • Improved cognitive function

  • Improved quality of life

Evidence of Effectiveness

There is strong evidence that case-managed care reduces use of nursing homes (Cochrane-Reilly 2015, Berthelsen 2015*, Samus 2014, Eloniemi-Sulkava 2009*, Allen 2000*, Bernabei 1998*) and hospital utilization (Armold 2017*, Bronstein 2015*, Meret-Hanke 2011*, Marek 2010*, Bernabei 1998*, Schifalacqua 2000*), and improves functioning among community-dwelling frail elders more than usual care (Marek 2010*, Trivedi 2012, Tappen 2001*, Marshall 1999*, Bernabei 1998*).

Case-managed care can extend the time before frail elders move to nursing homes (Berthelsen 2015*) and reduce length of stay (You 2013*). Such care can also reduce hospital admissions (Armold 2017*, Bernabei 1998*, Schifalacqua 2000*, Duke 2005*, Hammer 2001*, Landi 2001*, Landi 1999), readmissions (Bronstein 2015*), and length of stay for frail elders using case-managed care (Marek 2010*, Bernabei 1998*, Schifalacqua 2000*, Duke 2005*, Hammer 2001*, Landi 2001*, Landi 1999).

Case management can improve patients’ health outcomes (Trivedi 2012, Samus 2014) and reduce mortality (Coburn 2012). Such care may reduce falls, preserve mobility and the ability to maintain a household (Scharlach 2015) and complete activities of daily living (ADL) (Hammer 2001*), and improve quality of life (Lim 2003*, Hammer 2001*). Case management may also increase patient satisfaction (Trivedi 2012, Samus 2014, Hallberg 2004, Lim 2003*), caregiver satisfaction (Cochrane-Reilly 2015, Eklund 2009*, Callahan 2006 Sandberg 2015), and caregivers’ confidence (Berthelsen 2015*, Sandberg 2015). In some circumstances, case management can improve quality of care and reduce the use of emergency services (Marek 2010*) and emergency room visits (Armold 2017*).

Case management can also improve cognition, reduce depression (Marek 2005*) and dementia symptoms in patients with Alzheimer disease (Callahan 2006), and reduce behavioral disturbances for patients with dementia (Cochrane-Reilly 2015).

Some case management interventions appear to reduce total costs of care; however, outcomes vary by program, case manager, and duration of program (Cochrane-Reilly 2015, Trivedi 2012), (Joo 2014a). Municipalities (Berthelsen 2015*), Medicare (De Jonge 2014), and informal caregivers may benefit from cost reductions (Sandberg 2015). 

Impact on Disparities

No impact on disparities likely

Implementation Examples

The federal Program for All-Inclusive Care for the Elderly (PACE) offers home care with nurse management for Medicare and Medicaid enrollees eligible for nursing home care but able to safely remain at home. Examples of care covered by PACE includes adult day primary care, dentistry, emergency services, home care, physical therapy, and meals (CMS-PACE). As of 2016, there are over 100 independent PACE organizations across the US (CWF-Hostetter 2016).

Implementation Resources

CMS-PACE - Centers for Medicare & Medicaid Services (CMS). Program of all-inclusive care for the elderly (PACE).

Mountain Empire PACE - Mountain Empire Older Citizens Program of All-Inclusive Care for the Elderly (PACE). Pace provides loving care to participants and peace of mind to families.

Citations - Evidence

* Journal subscription may be required for access.

Cochrane-Reilly 2015 - Reilly S, Miranda-Castillo C, Malouf R, et al. Case management approaches to home support for people with dementia. Cochrane Database of Systematic Reviews. 2015;(1):CD008345.

Berthelsen 2015* - Berthelsen CB, Kristensson J. The content, dissemination and effects of case management interventions for informal caregivers of older adults: A systematic review. International Journal of Nursing Studies. 2015;52(5):988-1002.

Samus 2014 - Samus QM, Johnston D, Black BS, et al. A multidimensional home-based care coordination intervention for elders with memory disorders: the Maximizing Independence at Home (MIND) Pilot Randomized Trial. The American Journal of Geriatric Psychiatry. 2014;22(4):398-414.

Eloniemi-Sulkava 2009* - Eloniemi-Sulkava U, Saarenheimo M, Laakkonen M-L, et al. Family care as collaboration: Effectiveness of a multicomponent support program for elderly couples with dementia. Randomized controlled intervention study. Journal of the American Geriatrics Society. 2009;57(12):2200–8.

Allen 2000* - Allen S. Description and outcomes of a Medicare case management program by nurses. Home Health Care Services Quarterly. 2000;18(2):43-68.

Bernabei 1998* - Bernabei R, Landi F, Gambassi G, et al. Randomised trial of impact of model of integrated care and case management for older people living in the community. BMJ. 1998;316(7141):1348-1351.

Armold 2017* - Armold S. Utilization of the health care system of community case management patients. Professional Case Management. 2017;22(4):155-162.

Bronstein 2015* - Bronstein LR, Gould P, Berkowitz SA, James GD, Marks K. Impact of a social work care coordination intervention on hospital readmission: A randomized controlled trial. Social Work. 2015;60(3):248-255.

Meret-Hanke 2011* - Meret-Hanke LA. Effects of the program of all-inclusive care for the elderly on hospital use. The Gerontologist. 2011;51(6):774–85.

Marek 2010* - Marek KD, Adams SJ, Stetzer F, Popejoy L, Rantz M. The relationship of community-based nurse care coordination to costs in the Medicare and Medicaid programs. Research in Nursing & Health. 2010;33(3):235–42.

Schifalacqua 2000* - Schifalacqua M, Hook M, O’Hearn P, Schmidt M. Coordinating the care of the chronically ill in a world of managed care. Nursing Administration Quarterly. 2000;24(3):12-20.

Trivedi 2012 - Trivedi D, Goodman C, Gage H, et al. The effectiveness of inter-professional working for older people living in the community: A systematic review. Health and Social Care in the Community. 2013;21(2):113-28.

Tappen 2001* - Tappen RM, Hall RF, Folden SL. Impact of comprehensive nurse-managed transitional care. Clinical Nursing Research. 2001;10(3):295-313.

Marshall 1999* - Marshall BS, Long MJ, Voss J, Demma K, Skerl KP. Case management of the elderly in a health maintenance organization: The implications for program administration under managed care. Journal of Healthcare Management. 1999;44(6):477-493.

You 2013* - You EC, Dunt DR, Doyle C. Case managed community aged care: What is the evidence for effects on service use and costs? Journal of Aging and Health. 2013;25(7):1204-1242.

Duke 2005* - Duke C. The frail elderly community– based case management project. Geriatric Nursing. 2005;26(2):122-127.

Hammer 2001* - Hammer BJ. Community-based case management for positive outcomes. Geriatric Nursing. 2001;22(5):271-275.

Landi 2001* - Landi F, Onder G, Russo A, et al. A new model of integrated home care for the elderly: Impact on hospital use. Journal of Clinical Epidemiology. 2001;54(9):968-970.

Landi 1999 - Landi F, Gambassi G, Pola R, et al. Impact of integrated home care services on hospital use. Journal of the American Geriatrics Society. 1999;47(12):1430-1434.

Coburn 2012 - Coburn KD, Marcantonio S, Lazansky R, Keller M, Davis N. Effect of a community-based nursing intervention on mortality in chronically ill older adults: A randomized controlled trial. PLoS Medicine. 2012;9(7):e1001265.

Scharlach 2015 - Scharlach AE, Graham CL, Berridge C. An integrated model of co-ordinated community-based care. The Gerontologist. 2015;55(4):677-687.

Lim 2003* - Lim WK, Lambert SF, Gray LC. Effectiveness of case management and post-acute services in older people after hospital discharge. The Medical Journal of Australia. 2003;178(6):262-266.

Hallberg 2004 - Hallberg IR, Kristensson J. Preventive home care of frail older people: A review of recent case management studies. Journal of Clinical Nursing. 2004;13(6B):112–20.

Eklund 2009* - Eklund K, Wilhelmson K. Outcomes of coordinated and integrated interventions targeting frail elderly people: A systematic review of randomised controlled trials. Health & Social Care in the Community. 2009;17(5):447–58.

Callahan 2006 - Callahan CM, Unverzagt FW, Austrom MG, et al. Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: A randomized controlled trial. Journal of the American Medical Association. 2006;295(18):2148–57.

Sandberg 2015 - Sandberg M, Jakobsson U, Midlöv P, Kristensson J. Cost-utility analysis of case management for frail older people: Effects of a randomised controlled trial. Health Economics Review. 2015;5(1):12.

Marek 2005* - Marek KD, Popejoy L, Petroski G, et al. Clinical outcomes of aging in place. Nursing Research. 2005;54(3):202–11.

Joo 2014a - Joo JY, Huber DL. An integrative review of nurse-led community-based case management effectiveness. International Nursing Review. 2014;61(1):14-24.

De Jonge 2014 - De Jonge KE, Jamshed N, Gilden D, et al. Effects of home-based primary care on Medicare costs in high-risk elders. Journal of the American Geriatrics Society. 2014;62(10):1825-1831.

Citations - Implementation Examples

* Journal subscription may be required for access.

CMS-PACE - Centers for Medicare & Medicaid Services (CMS). Program of all-inclusive care for the elderly (PACE).

CWF-Hostetter 2016 - Hostetter M, Klein S, McCarthy D. Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community. New York: The Commonwealth Fund (CWF); 2016.

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