The work of case managers as experienced by older persons (75+) with multi-morbidity – a focused ethnography

BMC Geriatrics, Dec 2015

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.

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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)


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Markus Hjelm, Göran Holst, Ania Willman, Doris Bohman, Jimmie Kristensson. The work of case managers as experienced by older persons (75+) with multi-morbidity – a focused ethnography, BMC Geriatrics, 2015, pp. 168, 15, DOI: 10.1186/s12877-015-0172-3