The work of case managers as experienced by older persons (75+) with multi-morbidity – a focused ethnography
Hjelm et al. BMC Geriatrics
The work of case managers as experienced by older persons (75+) with multi-morbidity - a focused ethnography
Markus Hjelm 0 1
Göran Holst 1
Ania Willman 1 2
Doris Bohman 1
Jimmie Kristensson 0
0 Department of Health Sciences, Lund University , SE-221 00 Lund , Sweden
1 Department of Health, Blekinge Institute of Technology , SE-371 45 Karlskrona , Sweden
2 Department of Care Science, Malmö University , SE-211 18 Malmö , Sweden
Background: Complex health systems make it difficult for older persons (75+) with multi-morbidity to achieve continuity of care. Case management could be one way to address this difficulty. Currently, there is a need to extend the knowledge regarding case management as experienced by those utilising the services, namely older persons (75+) with multi-morbidity. The study aimed to explore older persons' (75+) with multi-morbidity experiences of case managers. Methods: The study design was qualitative and used a focused ethnographic approach. Data was collected through individual interviews with 13 older persons and by participant observations with accompanying field notes, all conducted in 2012-2013. Results: The data revealed four themes illustrating the older persons' experiences of case managers: 1) Someone providing me with a trusting relationship; 2) Someone assisting me; 3) Someone who is on my side; and 4) Someone I do not need at present. Conclusions: This study illustrates the importance of establishing trusting relationships between older persons and their case managers in order to truly provide assistance. The older persons valued the case managers acting as informed but unbiased facilitators. The findings could be of help in the development of case management interventions better designed for older persons with multi-morbidity.
Aged; Case management; Comorbidity; Continuity of patient care; Delivery of health care; Ethnography; Intervention; Multi-morbidity; Qualitative research
Background
Older persons with multi-morbidity i.e. multiple
independent diseases, are at risk of receiving fragmented
care because of complex health systems [
1–5
]. One
way of addressing this risk could be the use of case
management. Case management aims to improve the
coordination of health and social care, with the case
management interventions being performed by case
managers [
6
]. Previous research regarding case
management interventions targeting older persons has
displayed mixed results, for example some results have
indicated decreasing service use and costs while other
results displayed no change at all following the
intervention [
5, 7, 8
]. Furthermore, within these studies,
the interventional elements are often described in
limited detail, making it difficult to assess what had
actually been done as an intervention [
2, 5, 9, 10
].
There is a need for knowledge regarding experiences
of what actually takes place during a case
management intervention from the perspective of those
receiving the intervention [8], in this case the older
persons with multi-morbidity. Knowledge derived
from such studies could therefore help us to better
understand and further advance the progress and
design of case management interventions aimed at older
persons with multi-morbidity.
Among Europe’s aging population, a substantial
number of older persons have multi-morbidity [
11, 12
]. In
Sweden, having several chronic diseases is considered to
be the most common state of health for persons aged
75 years and older [13]. The same is seen internationally,
where the prevalence of multi-morbidity varies between
55 to 98 % amongst persons aged 65 years and older
[
14
]. The definition of multi-morbidity set by the
Swedish National Board of Health and Welfare in 2003 [
15
]
is: “being over 75 years, having three or more medical
diagnoses from different disease groups and also been
acutely admitted to hospital at least three times during
the last twelve months” [
15
]. The prevalence according
to this definition, a definition also used in the current
study, is estimated at 7 % of the Swedish population
[
13
]. Studies suggest that older persons with
multimorbidity can experience difficulty feeling involved in
their own care because of poor care coordination and a
high waiting time [
16, 17
]. They are at risk of
experiencing difficulties when coordinating care efforts, which
could lead to a lack of continuity of care [
1, 4
]. Lack of
coordination and the lack of an individual approach
within the health system for older persons exist
throughout the Western world [
6
]. This unsatisfactory
coordination could also put older persons’ health at risk, as they
might not receive the help they require [
18
]. This may
also have implications for older persons’ well-being as
they risk lacking energy to cope with other activities that
provide meaningfulness to their lives [
4
]. To reduce the
fragmentation of care, it has become increasingly
important to develop, (...truncated)