Case management in Hong Kong: evaluation of a pilot project in community nursing

Cost-Benefit Analysis of a Case Management Project for the Community-Dwelling Frail Elderly in Hong Kong

This randomized, controlled trial evaluates the cost-benefit of a case management project for older persons in HongKong. Case managers provided integrated care to participants in an intervention group while participants in a control group received conventional care only. Minimum Data Set–Home Care was used to assess health conditions, and hospital admissions were used as the basis to calculate health care costs. After the intervention, hospital admissions were reduced by 36.8% in the intervention group (p = .01) and 20.4% in the control group. The total number of acute hospital bed-days decreased by 53.1% in the intervention group (p < .05), compared to 4.4% in the control group. Compared with the control group, U.S.$170,448 was saved in acute hospital care and community health services in the intervention group. Well-planned case management interventions reduced hospital admissions and the length of stay in hospitals with corresponding savings in total health care costs.

Case managers for older persons with multi-morbidity and their everyday work - a focused ethnography

BACKGROUND

Modern-day health systems are complex, making it difficult to assure continuity of care for older persons with multi-morbidity. One way of intervening in a health system that is leading to fragmented care is by utilising Case Management (CM). CM aims to improve co-ordination of healthcare and social services. To better understand and advance the development of CM, there is a need for additional research that provides rich descriptions of CM in practice. This knowledge is important as there could be unknown mechanisms, contextual or interpersonal, that contribute to the success or failure of a CM intervention. Furthermore, the CM intervention in this study is conducted in the context of the Swedish health system, which prior to this intervention was unfamiliar with this kind of coordinative service. The aim of this study was to explore the everyday work undertaken by case managers within a CM intervention, with a focus on their experiences.

METHODS

The study design was qualitative and inductive, utilising a focused ethnographic approach. Data collection consisted of participant observations with field notes as well as a group interview and individual interviews with nine case managers, conducted in 2012/2013. The interviews were recorded, transcribed verbatim and subjected to thematic analysis.

RESULTS

An overarching theme emerged from the data: Challenging current professional identity, with three sub-themes. The sub-themes were 1) Adjusting to familiar work in an unfamiliar role; 2) Striving to improve the health system through a new role; 3) Trust is vital to advocacy.

CONCLUSIONS

Findings from this study shed some light on the complexity of CM for older persons with multi-morbidity, as seen from the perspective of case managers. The findings illustrate how their everyday work as case managers represents a challenge to their current professional identity. These findings could help to understand and promote the development of CM models aimed at a population of older persons with complex health needs.

Nurse follow-up of patients with diabetes: randomized controlled trial

AIM

This paper reports a study comparing the outcomes of diabetic patients undergoing either early discharge or routine care.

BACKGROUND

The hospital is not the best place to monitor the glycaemic control of patients with diabetes with no other morbidity or complications. It is an unnatural environment in which diet is planned and the activity level is low. The hospital is also an expensive place in which to treat patients.

METHODS

This randomized controlled trial was conducted in the medical department of a regional hospital in Hong Kong. A total of 101 patients who needed glycaemic monitoring, but who were otherwise fit for discharge, were recruited. The control group continued to receive routine hospital care. The study group was discharged early and received a follow-up programme which included a weekly or biweekly telephone call from a nurse.

FINDINGS

When compared with the control group, the study group had a greater decrease in HbA1c at 24 weeks, although the statistical difference was marginal (7.6 vs. 8.1, P = 0.06), a higher blood monitoring adherence score at both 12 weeks (5.4 vs. 3.6, P < 0.001) and 24 weeks (5.3 vs. 3.5, P < 0.001), and a higher exercise adherence score at 12 weeks (5.3 vs. 3.4, P = 0.001) and 24 weeks (5.5 vs. 3.2, P < 0.001). The study group had a shorter hospital stay (2.2 vs. 5.9, P < 0.001), and the net savings were HK$11,888 per patient.

CONCLUSION

It is feasible to integrate treatment into the real life environments of patients with diabetes, and nurse-led transitional care is a practical and cost-effective model. Nurse follow-up is effective in maintaining optimal glycaemic control and enhancing adherence to health behaviours. Management of glycaemic control is better done in the community than in the hospital.