Home Care Case Managers' Integrated Care of Older Adults With Multiple Chronic Conditions: A Scoping Review.

PURPOSE OF STUDY: The purpose of this scoping review was to explore peer-reviewed research and gray literature to examine the extent, range, and nature of available research that describes how home care case managers (HCCMs) provide integrated care for older adults with multiple chronic conditions (MCCs); identify how case management standards of practice correspond with functions of integrated care; identify facilitators and barriers to case management and integrated care delivery; and propose a framework to describe how HCCMs can use case management standards to provide integrated care to older adults with MCCs.

PRIMARY PRACTICE SETTING: Community, home care settings.

METHODOLOGY AND SAMPLE: Scoping review; older adults older than 65 years with MCCs, case managers and health care professionals who provide care for older adults with MCCs.

RESULTS: The study findings demonstrated that HCCMs consistently used the case management standards assessment, planning, implementation, and evaluation to provide all professional and clinical integrated care functions, and were least likely to use the standards of identification of client and eligibility for case management and transition to provide professional and clinical integrated care functions. In addition, HCCM use of professional and clinical integrated care functions was inconsistent and varied based on use of case management standards. All case management standards and integrated care functions were found to be both facilitators and barriers, but were more likely to facilitate HCCM work. Interestingly, the standards of assessment, planning, and implementation were more likely to facilitate functional integration, whereas the integrated care functions of intra- and interpartnerships, shared accountability, person centered of care, and engagement for client self-management were more likely to facilitate normative integration. We also found that HCCMs use case management standards and integrated care functions to provide care for older adults with MCCs at the professional (meso) and clinical (micro) levels.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Variations in HCCM practice may impact the delivery of case management standards when caring for older adults with MCCs. This has implications for the comprehensiveness and consistency of HCCM practice, as well as interdisciplinary health professional and the client's awareness of the HCCM role when providing integrated care to older adults with MCCs within home settings. The greatest facilitators and barriers to integrated care are those case management standards and clinical and professional integrated care functions that focus on partnerships, collective and shared responsibility and accountability, coordinated person centered of care for clients, and ensuring engagement and partnership in self-management. This indicates the need for development of case management policies and programs that support the work of HCCMs in the delivery of seamless and collaborative case management and integrated care functions that foster collaboration and partnership-building efforts. The development of a new case management and integrated care conceptual framework that includes case management standards, professional and clinical integrated care functions would guide HCCM integrated care practice, policy and research to support client and family-centered care, and foster shared values for sustainable partnerships across care settings.