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

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.