Case management’s effectiveness to yield positive outcomes for frail older persons living at home: a realist review

Van Durme, Thérèse [UCL] Cès, Sophie [UCL] Schmitz, Olivier [UCL] Macq, Jean [UCL]

Aim and background. Although many systematic reviews have been conducted over the last decade to assess the overall effectiveness of case management to achieve desirable outcomes for community-dwelling frail older persons, there is little evidence that the expected results are indeed achieved in terms of delaying unwanted institutionalisation, stabilising functional status, lower overall healthcare cost, reduce informal caregiver burden and improve quality of life. One of the reasons provided is the method of data pooling used in the meta-analyses in these reviews, by aggregating the information, despite the extreme heterogeneity of the case management interventions, i.e. components, activities and context. The aim of the systematic review was to provide one or more theories about why and how case management interventions were successful (or not) in their given contexts and for whom? Methods. A realist approach was used in order to define the mechanisms by which the case management interventions were linked to frail older persons’ outcomes in a given context. Therefore, we performed firstly a qualitative scoping, in order to ‘map the area’ and build a tentative theoretical framework. In a second step, we conducted a systematic review in MEDLINE, EMBASE, CINAHL, ISI Web of Knowledge, PsychInfo in Spring 2013. Reference list of selected papers were hand-searched. During an iterative process of discussion with a multidisciplinary team and further diving into the extracted information from the selected articles, we build and tested a theoretical framework of successful case management. As a result of the iterative research strategy and discussions, 87 papers were included in the analysis. A first theoretical framework was proposed, guided by D’Amour’s framework of collaborative professional care and linked to the outcomes of case management interventions studied. Four domains were identified: impact of the components of the interventions, impact of the characteristics of the target population, impact of the technologies or tools used and impact of the organisational strategies. Discussion. This review strategy yielded interesting and robust evidence about key components of case management interventions which can explain the success of failure of a case management intervention to achieve its goals, in a given context.