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Case-managed care for community-dwelling frail elders

Health Factors: Quality of Care
Decision Makers: Community Members State Government Healthcare Professionals & Advocates
Evidence Rating: Some Evidence
Population Reach: 1-9% of WI's population
Impact on Disparities: No impact on disparities likely

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In a case management model, health professionals, often nurses, manage multiple aspects of patients’ long-term care (LTC), including patient status assessment, monitoring, advocacy, care planning, and linkage to services, as well as transmission of information to and between service providers. Case managers often care for frail elderly patients who live independently. Frail elderly patients often have complex health needs that require care from multiple providers, and are at increased risk of adverse outcomes from conditions that could be prevented with early detection and treatment (Eklund 2009).

Expected Beneficial Outcomes

Reduced hospital utilization
Improved day-to-day functioning
Improved health outcomes
Increased patient satisfaction
Increased caregiver satisfaction
Reduced nursing home use
Improved mental health
Improved cognitive function

Evidence of Effectiveness

There is some evidence that case-managed care reduces hospitalization and improves functioning among community-dwelling frail elderly patients when compared to usual care (Hallberg 2004, Marek 2010). Additional evidence is needed to confirm effects.

Case management can improve patients’ health outcomes (Trivedi 2012) and satisfaction (Hallberg 2004, Trivedi 2012) as well as caregiver satisfaction (Eklund 2009, Callahan 2006). In some circumstances, case management can improve quality of care and reduce the need for emergency services (Marek 2010) or institutionalization (Hallberg 2004, Eloniemi-Sulkava 2009). Case management can also improve cognition, reduce depression (Marek 2005), and reduce dementia symptoms in patients with Alzheimer disease (Callahan 2006). Experts suggest that increased rehabilitative care for patients and education for caregivers could improve outcomes further (Hallberg 2004).

Some case management interventions appear to reduce total costs of care while others do not; outcomes vary by program and case manager (Trivedi 2012).


United States

The federal Program for All-Inclusive Care for the Elderly (PACE) offers home care with nurse management for Medicare and Medicaid enrollees eligible for nursing home care but safely able to remain at home (US DHHS-PACE). This program has demonstrated positive hospitalization (Meret-Hanke 2011), health, and basic function outcomes (Gabrowski 2006).

The Affordable Care Act (ACA) establishes a demonstration project to test models of nurse and physician-directed primary home care (AoA-ACA). Through the Community Living Assistance Services and Supports (CLASS) Act, ACA also establishes a voluntary insurance program to help participants pay for community living services.


Family Care, a long-term care (LTC) program in which social workers manage home or community-based care, is available in 57 Wisconsin counties (WI DHS-Family Care).

Citations - Description

Eklund 2009* - Eklund K, Wilhelmson K. Outcomes of coordinated and integrated interventions targeting frail elderly people: A systematic review of randomised controlled trials. Health & Social Care in the Community. 2009;17(5):447–58. Accessed on January 20, 2016

Citations - Evidence

Callahan 2006 - Callahan CM, Unverzagt FW, Austrom MG, et al. Effectiveness of collaborative care for older adults with alzheimer disease in primary care: A randomized controlled trial. Journal of the American Medical Association. 2006;295(18):2148–57. Accessed on December 1, 2015
Eklund 2009* - Eklund K, Wilhelmson K. Outcomes of coordinated and integrated interventions targeting frail elderly people: A systematic review of randomised controlled trials. Health & Social Care in the Community. 2009;17(5):447–58. Accessed on January 20, 2016
Eloniemi-Sulkava 2009* - Eloniemi-Sulkava U, Saarenheimo M, Laakkonen M-L, et al. Family care as collaboration: Effectiveness of a multicomponent support program for elderly couples with dementia. Randomized controlled intervention study. Journal of the American Geriatrics Society. 2009;57(12):2200–8. Accessed on December 28, 2015
Hallberg 2004 - Hallberg IR, Kristensson J. Preventive home care of frail older people: A review of recent case management studies. Journal of Clinical Nursing. 2004;13(6B):112–20. Accessed on February 5, 2016
Marek 2005* - Marek KD, Popejoy L, Petroski G, et al. Clinical outcomes of aging in place. Nursing Research. 2005;54(3):202–11. Accessed on March 14, 2016
Marek 2010* - Marek KD, Adams SJ, Stetzer F, Popejoy L, Rantz M. The relationship of community-based nurse care coordination to costs in the Medicare and Medicaid programs. Research in Nursing & Health. 2010;33(3):235–42. Accessed on March 1, 2016
Trivedi 2012 - Trivedi D, Goodman C, Gage H, et al. The effectiveness of inter-professional working for older people living in the community: A systematic review. Health and Social Care in the Community. 2013;21(2):113-28. Accessed on November 9, 2015

Citations - Implementation

AoA-ACA - Administration on Aging (AOA). Affordable Care Act: Opportunities for the aging network. Accessed on November 24, 2015
Gabrowski 2006* - Grabowski DC. The cost-effectiveness of noninstitutional long-term services: Review and synthesis of the most recent evidence. Medical Care Research and Review. 2006;63(1):3–28. Accessed on February 5, 2016
Meret-Hanke 2011* - Meret-Hanke LA. Effects of the program of all-inclusive care for the elderly on hospital use. The Gerontologist. 2011;51(6):774–85. Accessed on March 3, 2016
US DHHS-PACE - Program of all-inclusive care for the elderly (PACE). Accessed on January 26, 2016
WI DHS-Family Care - Wisconsin Department of Health Services (DHS). Family Care: Options for long-term care. Accessed on November 18, 2015

Page Last Updated

January 5, 2015

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