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Background and aim Although it is known that case management for frail older persons (FOP) is more likely to foster positive outcomes when the case manager works closely with the primary care physicians (PCP) [1], engaging PCPs to collaborate is often a difficult process, especially when the case management function is new [2]. The aim of this study was to provide insight on how newly implemented case management projects managed to engage FOPs’ PCP in the case management process, (to what extent?)and with which results. Methods A stepped approach was used to build the data collection, as (qualitative and quantitative) data were collected annually (from/within)among the 21 case management projects financed by the Belgian National Institute of Health and Disability Insurance (NIHDI) from the start of the projects (April 2010) till June 2013 (from records? Interviews?...). At total of 4612 FOPs were included in the 21 case management projects. Data collection and inductive analysis were informed by D’Amour’s framework of collaboration [3]. Results The entry point for most of the projects to try to engage PCPs in the process was the need for the latter filling out the medical part of the comprehensive geriatric assessment (InterRAI-HC), a cornerstone of the case management process. Strategies to engage PCPs ranged from solely providing information to the GP of the FOP being in the project (8 projects) to provision of full feed-back about the results of the interRAI-HC (10 projects). Only parts of D’Amour’s framework were used to guide these strategies, explaining the mixed results of PCPs’ engagement. Discussion and conclusions Strategies used by case management projects remained timid and the perceived PCP engagement in the case management process, weak. More targeted strategies are needed to enhance PCPs’ involvement and the use of theoretical frameworks, such as D’Amour’s, to guide those strategies, is expected to facilitate PCPs’ involvement.

Background / Objective: In the international literature, case management is often found to be a valuable way of organizing home care services and providing continuity of care. However, not many studies have provided evidence that case management can be effective in delaying institutionalization of older persons. The Belgian federal government is interested in funding home care projects that attain this goal. Twenty two case management projects will be analyzed during a 4-year period to reach a policy decision. Methods: Professional caregivers are asked to fill out the comprehensive geriatric assessment interRAI Home Care (HC) and an ad-hoc economic questionnaire describing the social services use and the time of informal care Informal caregivers also fill out the Zarit Burden scale 12 items and older persons fill out the WHOQOL-8. After descriptive statistics, the study population is stratified according to impairment levels (ADL, depression and cognition). Multivariate analyses are performed to identify significant associations and the effect of case management on the delay of institutionalization. Results: The study population consists of frail older persons in 21 case management projects (n=8534, average age: 79.7 median age 81.0, 67.6% women. The total of older persons in case management projects is 5004. This population shows moderate to high ADL impairment (47% CI(0.45 - 0.48)), moderate to high cognitive problems (27% CI(0.25 - 0.27)) and daily depression symptoms (27% CI(.25 - .28). These clients will be compared to a population not receiving any case management. International Journal of Integrated Care – Volume 14, 01 October – URN:NBN:NL:UI:10-1-116159– http://www.ijic.org/ Conclusion: This research will show the effect of case management combined with home care interventions in order to delay institutionalization of older persons. This information can help home care providers to adapt their services into a more integrated form of care model where case man

BACKGROUND: Various elderly case management projects have been implemented in Belgium. This type of long-term health care intervention involves contextual factors and human interactions. These underlying complex mechanisms can be usefully informed with field experts' knowledge, which are hard to make explicit. However, computer simulation has been suggested as one possible method of overcoming the difficulty of articulating such elicited qualitative views. METHODS: A simulation model of case management was designed using an agent-based methodology, based on the initial qualitative research material. Variables and rules of interaction were formulated into a simple conceptual framework. This model has been implemented and was used as a support for a structured discussion with experts in case management. RESULTS: The rigorous formulation provided by the agent-based methodology clarified the descriptions of the interventions and the problems encountered regarding: the diverse network topologies of health care actors in the project; the adaptation time required by the intervention; the communication between the health care actors; the institutional context; the organization of the care; and the role of the case manager and his or hers personal ability to interpret the informal demands of the frail older person. CONCLUSION: The simulation model should be seen primarily as a tool for thinking and learning. A number of insights were gained as part of a valuable cognitive process. Computer simulation supporting field experts' elicitation can lead to better-informed decisions in the organization of complex health care interventions.

Recommendations There is a need to look at the “best fit” between beneficiaries’ characteristics and interventions but also at the real target population of Protocol 3 projects InterRAI HC: allowed for stratification of the population (4 scales: IADL, ADL, DRS and CPS) + motivated projects to fill out because usable output Large variety of projects coupled with different types of beneficiaries – evaluation aimed at finding the most suitable combinations

Background / aim Informal caregivers (ICs) are crucial partners in the care for older persons and play an important role in helping them stay at home. The Belgian government is interested in delaying institutionalization of older persons. As a major predictor of institutionalization, IC’s burden is explored in this paper in order to identify its significant determinants. This is relevant information for home care providers to manage these determinants and try to decrease IC’s burden. Methods Nationwide, professional caregivers fill out the comprehensive geriatric assessment interRAI HomeCare and informal caregivers fill out the Zarit-12 and an economic questionnaire. After descriptive statistics are calculated, the study population is stratified according to impairment levels (ADL, IADL and cognition). Multivariate analyses are performed to analyze significant associations. Results The study population consists of frail older persons (n=4389, average age: 80.2, 67% women) who are benefiting from home care projects and who have IC (spouses (54.9%) or children (32.3%), etc.). Behavioral problems and older person’s depressive symptoms are significant determinants for IC burden in all strata (low, medium and high impairment), mainly for cohabitants. IADL impairment and time spent in care is a significant determinant for burden of non-cohabitants at low and medium impairment strata. Cognitive problems are significant determinants for burden at high impairment level.

The Belgian health care system is largely fragmented and not proactive enough to face the increased proportion of frail older persons living with multimorbid conditions. Case management (CM) is expected to be one of the responses to overcome health care system weaknesses. The aim of the research was to study the conditions and the mechanisms through which newly implemented CM projects in Belgium could be effective. Mixed methods were used. Firstly, we compared groups of frail older persons included in CM projects to frail older persons also in home care projects, but without CM. We studied the statistical association between benefiting from a CM project and (health and cost) outcome variables. The main outcome was the risk of institutionalization. Secondly, five case studies were conducted to provide an in-depth analysis of the projects, in order to shed light upon how the CM projects worked (mechanisms), for whom, under which conditions and why (realist approach). Internal and external validity was sought through data, theoretical and methodological triangulation. Findings are related to the conditions under which CM projects are expected to provide positive outcomes, such as case managers' profile and training, the adequacy and acceptability of information flow, the importance of GPs' involvement and the consistency of the CM with the values of both care providers and older persons. The realist approach used in this mixed method design yields robust evidence about the projects components and mechanisms affecting frail older people's outcomes in their specific context.

Background Various elderly case management projects have been implemented in Belgium. This type of long-term health care intervention involves contextual factors and human interactions. These underlying complex mechanisms can be usefully informed with field experts’ knowledge, which are hard to make explicit. However, computer simulation has been suggested as one possible method of overcoming the difficulty of articulating such elicited qualitative views. Methods A simulation model of case management was designed using an agent-based methodology, based on the initial qualitative research material. Variables and rules of interaction were formulated into a simple conceptual framework. This model has been implemented and was used as a support for a structured discussion with experts in case management. Results The rigorous formulation provided by the agent-based methodology clarified the descriptions of the interventions and the problems encountered regarding: 1 the diverse network topologies of health care actors in the project; 2 the adaptation time required by the intervention; 3 the communication between the health care actors; 4 the institutional context; 5 the organization of the care; and 6 the role of the case manager and his or hers personal ability to interpret the informal demands of the frail older person. Conclusion The simulation model should be seen primarily as a tool for thinking and learning. A number of insights were gained as part of a valuable cognitive process. Computer simulation supporting field experts’ elicitation can lead to better-informed deci- sions in the organization of complex health care interventions.

Purpose/objectives: The Belgian National Institute for Health and Disability Insurance (NIHDI) is interested in delaying institutionalization of older persons. Informal caregivers play an important role in maintaining the health, well-being, functional performance and quality of life of older people living at home. The aim of this paper is to identify whether innovative projects in home care are statistically associated with decreasing the informal caregiver’s perceived burden. Background/Methods: The study uses the interRAI HC instrument and a shorter version of the original 22-Zarit Burden Interview. In this ongoing study we have a population of 4346 frail older persons who have an informal caregiver and who are benefiting from innovative projects in home care. Through multivariate logistic regression researchers analyze the effect of the projects in the burden of caregivers. This method enables researchers to take into account factors such as the older person’s cognitive functioning, ADL performance, depressive symptoms, as well as the informal caregivers’ characteristics. Conclusions: This research will provide knowledge on perceived burden and will show whether some types of interventions may have a positive effect on decreasing the burden in giving care. This is important information for home care agencies but also useful information for policy makers at a societal level.

Afin de permettre aux personnes âgées fragiles de rester chez elles, les autorités responsables du remboursement des soins de santé financent, de façon bottom up, 66 projets-pilotes de soins innovants durant 4 ans. Le premier objectif de l’évaluation scientifique est d’évaluer l’efficience des projets. Il s’agit de réaliser une étude de type coût-efficacité. Le coût est estimé dans la perspective sociétale afin de prendre en compte l’ensemble des implications économiques des projets. L’efficacité se décline selon différentes dimensions : la prévention de l’institutionnalisation, la qualité de vie des personnes âgées, le fardeau porté par leur aidant informel principal, le déclin fonctionnel. Ceci doit permettre de proposer des types d’intervention à généraliser. Le deuxième objectif de l’évaluation scientifique vise à comprendre les résultats en terme d’efficience au travers d’une étude en profondeur de la mise en œuvre des projets et de leur contexte Ceci doit aboutir à des recommandations concernant les conditions favorables de mise en œuvre et de fonctionnement des projets. . Le devis général s’inscrit dans un cadre méthodologique concernant l’évaluation des interventions complexes: (1) une approche théorique, à partir d’une revue de littérature pour réaliser le protocole d’évaluation ; (2) une approche ancrée à partir de l’analyse d’implantation des projets et (3) une approche pragmatique pour la récolte des données. Depuis le 1er avril 2010, les 66 projets ont été caractérisés en fonction des composantes pouvant avoir un impact sur les personnes âgées fragiles. L’analyse du processus de démarrage des projets a permis d’identifier les menaces et opportunités.

Introduction and background : The Belgian national social health insurance system (INAMI/RIZIV) will finance alternative forms of care, in order to prevent institutionalization of the community-dwelling frail elderly. Bottom-up projects will receive grants if they propose innovative forms of care and support of care provided in a patient-centred and concerted way, if they target community dwelling frail elderly people with complex care needs and their informal caregivers and finally, if they prevent institutionalization of frail elderly. This paper presents the design of a protocol for the scientific evaluation of these projects. Its aim is to provide evidence to assist RIZIV/INAMI and other public authorities in future long term innovative care programs decision making. Methods : The general design has been driven by complex intervention evaluation methodologies, and performed by a multidisciplinary team, including nurses (MPH), GPs, epidemiologists, geriatricians, economists and sociologists. Three types of approaches were used: (1) a theory driven approach, through a literature review for model design; (2) a grounded approach, through candidate projects review and (3) a pragmatic approach for data collection, including tools chosen by the INAMI/RIZIV in previous projects. Results : Given the heterogeneity of the projects to be tested and their complex nature, 4 key objectives, related to 4 types of evaluations, are proposed. 1. Modelling the project components as part of a care system, to clarify mechanisms through which the projects could influence outcomes for frail elderly; 2. Performing an process implementation evaluation to identify threats and opportunities; 3. Performing an evaluation of outcomes for frail elderly and informal caregivers; 4.Performing an economic evaluation to assess various dimensions of the total cost of home maintaining when and the efficiency for the different types of projects. The Chronic Care model (Wagner et al., 1996) is used for