title: Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation.
abstract: BACKGROUND
  In 2009, the English Department of Health appointed 16 integrated care pilots which aimed to provide better integrated care. We report the quantitative results from a multi-method evaluation of six of the demonstration projects which used risk profiling tools to identify older people at risk of emergency hospital admission, combined with intensive case management for people identified as at risk. The interventions focused mainly on delivery system redesign and improved clinical information systems, two key elements of Wagner's Chronic Care Model.
  
  
  METHODS
  Questionnaires to staff and patients. Difference-in-differences analysis of secondary care utilisation using data on 3646 patients and 17,311 matched controls, and changes in overall secondary care utilisation.
  
  
  RESULTS
  Most staff thought that care for their patients had improved. More patients reported having a care plan but they found it significantly harder to see a doctor or nurse of their choice and felt less involved in decisions about their care. Case management interventions were associated with a 9% increase in emergency admissions. We found some evidence of imbalance between cases and controls which could have biased this estimate, but simulations of the possible effect of unobserved confounders showed that it was very unlikely that the sites achieved their goal of reducing emergency admissions. However, we found significant reductions of 21% and 22% in elective admissions and outpatient attendance in the six months following an intervention, and overall inpatient and outpatient costs were significantly reduced by 9% during this period. Area level analyses of whole practice populations suggested that overall outpatient attendances were significantly reduced by 5% two years after the start of the case management schemes.
  
  
  CONCLUSIONS
  Case management may result in improvements in some aspects of care and has the potential to reduce secondary care costs. However, to improve patient experience, case management approaches need to be introduced in a way which respects patients' wishes, for example the ability to see a familiar doctor or nurse.
authors.affiliation: Cambridge Centre for Health Services Research, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Roland
authors.forename: Richard
authors.initials: R
authors.lastname: Lewis
authors.forename: Adam
authors.initials: A
authors.lastname: Steventon
authors.forename: Gary
authors.initials: G
authors.lastname: Abel
authors.forename: John
authors.initials: J
authors.lastname: Adams
authors.forename: Martin
authors.initials: M
authors.lastname: Bardsley
authors.forename: Laura
authors.initials: L
authors.lastname: Brereton
authors.forename: Xavier
authors.initials: X
authors.lastname: Chitnis
authors.forename: Annalijn
authors.initials: A
authors.lastname: Conklin
authors.forename: Laura
authors.initials: L
authors.lastname: Staetsky
authors.forename: Sarah
authors.initials: S
authors.lastname: Tunkel
authors.forename: Tom
authors.initials: T
authors.lastname: Ling
keywords: England; case management; hospital utilization; integrated care; older people; patient experience; risk stratification; staff experience