CADTH RAPID RESPONSE REPORT: REFERENCE LIST
Case Management for Frail
Elderly in the Community
Setting: Clinical
Effectiveness, CostEffectiveness, and
Guidelines
Service Line:
Version:
Publication Date:
Report Length:
Rapid Response Service
1.0
March 20, 2017
9 Pages
Authors: Charlotte Wells, Sarah Jones
Cite As: Case management for frail elderly in the community setting: Clinical effectiveness, cost-effectiveness, and guidelines. Ottawa: CADTH; 2017 Mar.
(CADTH rapid response report: reference list).
Acknowledgments:
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REFERENCE LIST Case Management for Frail Elderly in the Community Setting
2
Research Questions
1. What is the clinical effectiveness of case management for frail elderly in the
community?
2. What is the cost-effectiveness of case management for frail elderly in the community?
3. What are the evidence-based guidelines regarding case management interventions
for frail elderly in the community?
Key Findings
One health technology assessment, seven systematic reviews and meta-analyses, 15
randomized control trials, and four economic evaluations were identified regarding case
management for frail elderly in the community setting. Additionally, two evidence-based
guidelines were identified regarding case management for frail elderly in the community
setting.
Methods
A limited literature search was conducted on key resources including PubMed, The
Cochrane Library, University of York Centre for Reviews and Dissemination (CRD)
databases, Canadian and major international health technology agencies, as well as a
focused Internet search. Methodological filters were applied to limit retrieval to health
technology assessments, systematic reviews, meta-analyses, randomized controlled trials,
economic studies, and guidelines. Where possible, retrieval was limited to the human
population. The search was also limited to English language documents published between
January 1, 2012 and March 15, 2017. Internet links were provided, where available.
Selection Criteria
One reviewer screened citations and selected studies based on the inclusion criteria
presented in Table 1.
Table 1: Selection Criteria
Population
Frail elderly living at home (including those with dementia), excluding long-term care, acute care, hospital,
primary care, etc.
Intervention
Case management
Comparator
Usual care or community-based care without case management
REFERENCE LIST Case Management for Frail Elderly in the Community Setting
3
Outcomes
Effectiveness, clinical benefit or harm, safety, cost, guidelines
Study Designs
Health technology assessments, systematic reviews, meta-analyses, randomized control trials, economic
evaluations, evidence-based guidelines
Results
Rapid Response reports are organized so that the higher quality evidence is presented first.
Therefore, health technology assessment reports, systematic reviews, and meta-analyses
are presented first. These are followed by randomized controlled trials, economic
evaluations, and evidence-based guidelines.
One health technology assessment, seven systematic reviews and meta-analyses, 15
randomized control trials, and four economic evaluations were identified regarding case
management for frail elderly in the community setting. Additionally, two evidence-based
guidelines were identified regarding case management for frail elderly in the community
setting.
Additional references of potential interest are provided in the appendix.
Health Technology Assessments
1.
Health Quality Ontario. In-home care for optimizing chronic disease management in the
community: an evidence-based analysis. Ont Health Technol Assess Ser [Internet].
2013 September [cited 2017 Mar 20];13(5):1–65. Available from:
http://www.hqontario.ca/en/documents/eds/2013/full-report-OCDM-in-home-care.pdf.
Systematic Reviews and Meta-analyses
2.
Reilly S, Miranda-Castillo C, Malouf R, Hoe J, Toot S, Challis D, et al. Case
management approaches to home support for people with dementia. Cochrane
Database Syst Rev. 2015 Jan 5;1:CD008345.
PubMed: PM25560977
3.
Oregon Evidence-based Practice Center, Hickam DH, Weiss JW, Guise J, Buckley D,
Motu’apaka M, et al. Outpatient case management for adults with medical illness and
complex care needs [Internet]. Rockville (MD): Agency for Healthcare Research and
Quality (AHRQ); 2013 Jan. (Comparative effectiveness review; no. 99). [cited 2017 Mar
20]. Available from: https://effectivehealthcare.ahrq.gov/search-for-guides-reviews-andreports/?pageaction=displayproduct&productid=1369
4.
Huntley AL, Thomas R, Mann M, Huws D, Elwyn G, Paranjothy S, et al. Is case
management effective in reducing the risk of unplanned hospital admissions for older
people? A systematic review and meta-analysis. Fam Pract. 2013 Jun;30(3):266-75.
PubMed: PM23315222
5.
Tam-Tham H, Cepoiu-Martin M, Ronksley PE, Maxwell CJ, Hemmelgarn BR. Dementia
case management and risk of long-term care placement: a systematic review and
meta-analysis. Int J Geriatr Psychiatry. 2013 Sep;28(9):889-902.
PubMed: PM23188735
REFERENCE LIST Case Management for Frail Elderly in the Community Setting
4
6.
Cooper C, Mukadam N, Katona C, Lyketsos CG, Ames D, Rabins P, et al. Systematic
review of the effectiveness of non-pharmacological interventions to improve quality of
life of people with dementia. Int Psychogeriatr. 2012 Jun;24(6):856-70.
PubMed: PM22244371
7.
Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Interventions for improving
outcomes in patients with multimorbidity in primary care and community settings.
Cochrane Database Syst Rev. 2012 Apr 18;(4):CD006560.
PubMed: PM22513941
8.
You EC, Dunt D, Doyle C, Hsueh A. Effects of case management in community aged
care on client and carer outcomes: a systematic review of randomized trials and
comparative observational studies. BMC Health Serv Res [Internet]. 2012 Nov 14 [cited
2017 Mar 20];12:395. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508812
PubMed: PM23151143
Randomized Controlled Trials
9.
McElrath M, Myers J, Chan K, Fonda H. Exercise adherence in the elderly: Experience
with abdominal aortic aneurysm simple treatment and prevention. J Vasc Nurs. 2017
Mar;35(1):12-20.
PubMed: PM28224946
10. Bruce ML, Lohman MC, Greenberg RL, Bao Y, Raue PJ. Integrating Depression Care
Management into Medicare Home Health Reduces Risk of 30- and 60-Day
Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial.
J Am Geriatr Soc [Internet]. 2016 Nov [cited 2017 Mar 20];64(11):2196-203. Available
from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5118110
PubMed: PM27739067
11. Godwin M, Gadag V, Pike A, Pitcher H, Parsons K, McCrate F, et al. A randomized
controlled trial of the effect of an intensive 1-year care management program on
measures of health status in independent, community-living old elderly: the Eldercare
project. Fam Pract. 2016 Feb;33(1):37-41.
PubMed: PM26560094
12. Yu DS. Effects of a health and social collaborative case management model on health
outcomes of family caregivers of frail older adults: Preliminary data from a pilot
randomized controlled trial. J Am Geriatr Soc [Internet]. 2016 Oct [cited 2017 Mar
20];64(10):2144-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27550619
13. Bruce ML, Raue PJ, Reilly CF, Greenberg RL, Meyers BS, Banerjee S, et al. Clinical
effectiveness of integrating depression care management into medicare home health:
the Depression CAREPATH Randomized trial. JAMA Intern Med [Internet]. 2015 Jan
[cited 2017 Mar 20];175(1):55-64. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4516039
PubMed: PM25384017
REFERENCE LIST Case Management for Frail Elderly in the Community Setting
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14. Hunger M, Kirchberger I, Holle R, Seidl H, Kuch B, Wende R, et al. Does nurse-based
case management for aged myocardial infarction patients improve risk factors, physical
functioning and mental health? The KORINNA trial. Eur J Prev Cardiol. 2015
Apr;22(4):442-50.
PubMed: PM24523431
15. Kirchberger I, Hunger M, Stollenwerk B, Seidl H, Burkhardt K, Kuch B, et al. Effects of
a 3-year nurse-based case management in aged patients with acute myocardial
infarction on rehospitalisation, mortality, risk factors, physical functioning and mental
health. a secondary analysis of the randomized controlled KORINNA study. PLoS ONE
[Internet]. 2015 [cited 2017 Mar 20];10(3):e0116693. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374800
PubMed: PM25811486
16. Mavandadi S, Benson A, DiFilippo S, Streim JE, Oslin D. A Telephone-based program
to provide symptom monitoring alone vs symptom monitoring plus care management
for late-life depression and anxiety: A randomized clinical trial. JAMA Psychiatry. 2015
Dec;72(12):1211-8.
PubMed: PM26558530
17. Sandberg M, Kristensson J, Midlov P, Jakobsson U. Effects on healthcare utilization of
case management for frail older people: a randomized controlled trial (RCT). Arch
Gerontol Geriatr. 2015 Jan;60(1):71-81.
PubMed: PM25459920
18. Chow SK, Wong FK. A randomized controlled trial of a nurse-led case management
programme for hospital-discharged older adults with co-morbidities. J Adv
Nurs.[Internet] 2014 Oct [cited 2017 Mar 20];70(10):2257-71. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263097
PubMed: PM24617755
19. Moller UO, Kristensson J, Midlov P, Ekdahl C, Jakobsson U. Effects of a one-year
home-based case management intervention on falls in older people: a randomized
controlled trial. J Aging Phys Act. 2014 Oct;22(4):457-64.
PubMed: PM24152667
20. Senior HE, Parsons M, Kerse N, Chen MH, Jacobs S, Hoorn SV, et al. Promoting
independence in frail older people: a randomised controlled trial of a restorative care
service in New Zealand. Age Ageing. 2014 May;43(3):418-24.
PubMed: PM24598085
21. Jeong H, Yim HW, Jo SJ, Nam B, Kwon SM, Choi JY, et al. The effects of care
management on depression treatment in a psychiatric clinic: a randomized controlled
trial. Int J Geriatr Psychiatry. 2013 Oct;28(10):1023-30.
PubMed: PM23255054
22. Meisinger C, Stollenwerk B, Kirchberger I, Seidl H, Wende R, Kuch B, et al. Effects of a
nurse-based case management compared to usual care among aged patients with
myocardial infarction: results from the randomized controlled KORINNA study. BMC
Geriatr [Internet]. 2013 Oct 29 [cited 2017 Mar 20];13:115. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3871021
PubMed: PM24168465
REFERENCE LIST Case Management for Frail Elderly in the Community Setting
6
23. Upatising B, Hanson GJ, Kim YL, Cha SS, Yih Y, Takahashi PY. Effects of home
telemonitoring on transitions between frailty states and death for older adults: a
randomized controlled trial. Int J Gen Med [Internet]. 2013 [cited 2017 Mar 20];6:14551. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603330
PubMed: PM23525664
Economic Evaluations
24. Looman WM, Huijsman R, Bouwmans-Frijters CA, Stolk EA, Fabbricotti IN. Costeffectiveness of the 'Walcheren Integrated Care Model' intervention for communitydwelling frail elderly. Fam Pract [Internet]. 2016 Apr [cited 2017 Mar 20];33(2):154-60.
Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4793802
PubMed: PM26811438
25. MacNeil VJ, Bosmans JE, Eekhout I, Joling KJ, van Mierlo LD, Meiland FJ, et al. The
cost-effectiveness of two forms of case management compared to a control group for
persons with dementia and their informal caregivers from a societal perspective. PLoS
ONE [Internet]. 2016 [cited 2017 Mar 20];11(9):e0160908. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5031395
PubMed: PM27655234
26. Sandberg M, Jakobsson U, Midlov P, Kristensson J. Cost-utility analysis of case
management for frail older people: effects of a randomised controlled trial. Health Econ
Rev [Internet]. 2015 Dec [cited 2017 Mar 20];5(1):51. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4449349
PubMed: PM26054487
27. Seidl H, Hunger M, Leidl R, Meisinger C, Wende R, Kuch B, et al. Cost-effectiveness of
nurse-based case management versus usual care for elderly patients with myocardial
infarction: results from the KORINNA study. Eur J Health Econ. 2015 Jul;16(6):671-81.
PubMed: PM25108626
Guidelines and Recommendations
28. Integrated care clinical pharmacist for frail older people: Case management and
enhanced rapid response. London (GB): National Institute for Health and Care
Excellence; 2015 Sep. [cited 2017 Mar 20]. (NICE shared Learning Database).
Available from: https://www.nice.org.uk/sharedlearning/integrated-care-clinicalpharmacist-for-frail-older-people-case-management-and-enhanced-rapid-response
29. Leland N, Elliott SJ, Johnson KJ. Occupational therapy practice guidelines for
productive aging for community-dwelling older adults. Bethesda (MD): American
Occupational Therapy Association, Inc. (AOTA); 2012.
REFERENCE LIST Case Management for Frail Elderly in the Community Setting
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Appendix — Further Information
Systematic Review – Alternate Outcomes
30. Khanassov V, Vedel I, Pluye P. Barriers to implementation of case management for
patients with dementia: a systematic mixed studies review. Ann Fam Med [Internet].
2014 Sep [cited 2017 Mar 20];12(5):456-65. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4157983
PubMed: PM25354410
Randomized Control Trials – Alternate Comparator
31. Chodosh J, Colaiaco BA, Connor KI, Cope DW, Liu H, Ganz DA, et al. Dementia care
management in an underserved community: The comparative effectiveness of two
different approaches. J Aging Health. 2015 Aug;27(5):864-93.
PubMed: PM25656074
Non-Randomized Studies
32. de Almeida MJ, Declercq A, Ces S, Van DT, Van AC, Macq J. Exploring home care
interventions for frail older people in Belgium: A comparative effectiveness study. J Am
Geriatr Soc. 2016 Nov;64(11):2251-6.
PubMed: PM27676585
33. Schubert CC, Myers LJ, Allen K, Counsell SR. Implementing geriatric resources for
assessment and care of elders team care in a veterans affairs medical center: Lessons
learned and effects observed. J Am Geriatr Soc. 2016 Jul;64(7):1503-9.
PubMed: PM27305428
34. de SM, Vedel I, Buyck JF, Lapointe L, Bergman H, Beland F, et al. Impact on hospital
admissions of an integrated primary care model for very frail elderly patients. Arch
Gerontol Geriatr. 2014 May;58(3):350-5.
PubMed: PM24508468
Economic Evaluations – Alternate Comparator
35. Gage H, Ting S, Williams P, Drennan V, Goodman C, Iliffe S, et al. Nurse-led case
management for community dwelling older people: an explorative study of models and
costs. J Nurs Manag. 2013 Jan;21(1):191-201.
PubMed: PM23339509
Clinical Practice Guidelines – Unclear Methodology
36. Stewart S, Riegel B, Boyd C, Ahamed Y, Thompson DR, Burrell LM, et al. Establishing
a pragmatic framework to optimise health outcomes in heart failure and multimorbidity
(ARISE-HF): A multidisciplinary position statement. Int J Cardiol. 2016 Jun 1;212:1-10.
PubMed: PM27015641
37. Frailty in older adults - early identification and management [Internet]. Victoria (BC):
Guidelines & Protocols Advisory Committee; 2012 Jan 18. [cited 2017 Mar 20].
Available from: http://www2.gov.bc.ca/gov/content/health/practitioner-professionalresources/bc-guidelines/frailty
REFERENCE LIST Case Management for Frail Elderly in the Community Setting
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Review Articles
38. Hasche LK, Lavery A. "As needed" case management across aging services in
response to depression. J Gerontol Soc Work. 2015;58(3):272-88.
PubMed: PM25587880
39. Low LF, Fletcher J. Models of home care services for persons with dementia: a
narrative review. Int Psychogeriatr. 2015 Oct;27(10):1593-600.
PubMed: PM25672570
40. Van DT, Schmitz O, Ces S, Anthierens S, Maggi P, Delye S, et al. A comprehensive
grid to evaluate case management's expected effectiveness for community-dwelling
frail older people: results from a multiple, embedded case study. BMC Geriatr
[Internet]. 2015 Jun 18 [cited 2017 Mar 20];15:67. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4472179
PubMed: PM26084701
41. Veras RP, Caldas CP, Motta LB, Lima KC, Siqueira RC, Rodrigues RT, et al.
Integration and continuity of Care in health care network models for frail older adults.
Rev Saude Publica [Internet]. 2014 Apr [cited 2017 Mar 20];48(2):357-65. Available
from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4206139
PubMed: PM24897058
42. Community-based service models for seniors [Internet]. St. John's (NL): Newfoundland
and Labrador Centre for Applied Health Research, Memorial University; 2013. [cited
2017 Mar 17]. (Evidence in context). Available from:
http://www.nlcahr.mun.ca/CHRSP/CSMS.php
See: Contextual factors affecting case management
43. You EC, Dunt DR, Doyle C. Case managed community aged care: what is the
evidence for effects on service use and costs? J Aging Health. 2013 Oct;25(7):1204PubMed: PM23958520
Additional References
44. Swinson Evans T, Berkman N, Brown C, Gaynes B, Palmieri Weber R. Disparities
within serious mental illness [Internet]. Rockville (MD): Agency for Healthcare
Research and Quality (AHRQ); 2016 [cited 2017 Mar 20]. (Technical Brief No. 25.).
Available from:
https://www.effectivehealthcare.ahrq.gov/ehc/products/619/2236/mental-illnessdisparities-report-160524.pdf
See: Interventions for the Elderly
REFERENCE LIST Case Management for Frail Elderly in the Community Setting
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