The findings originate from the ethnographic analysis describing how older persons (75+) with multi-morbidity experienced case managers. From the data, four themes emerged: 1) Someone providing me with a trusting relationship; 2) Someone assisting me; 3) Someone who is on my side; and 4) Someone I do not need at present.
Someone providing me with a trusting relationship
Most of the participants stated that they experienced trusting relationships with their case manager. The participants felt a genuine trust in the case managers’ abilities and intentions to help them, and stated that the case managers had been available for them during times of need. They trusted that the case managers would always try their best in order to help them with their current concerns. Their trusting relationships with the case managers made them feel more secure that they would cope if future concerns related to their health and social care were to arise:
“If you need help they can assist you … that’s the advantage, it gives you a sense of security, you know that there is somebody who can help you.” (Participant 2)
The participants perceived that the case managers were fit for their jobs and they also noticed that the case managers appreciated their current assignments. They expressed a liking for the case managers’ personal traits. Some of the common personal traits associated with the case managers were: easy to talk to, friendly, light-hearted, cheerful and sensible. These traits were considered beneficial amongst the participants in order for them to open up and start trusting the case managers:
“You have to ‘read’ a person and … I found that she was nice, which makes you feel that you can open up.” (Participant 3)
The participants spoke about how the case managers engaged in social conversations with them, which could be about everyday things. They appreciated that the case managers took time to sit down and listen to parts of their life history. Some of the participants noted the contrast between these conversations and their former experiences of a lack of time for conversation when interacting with staff from the health system:
“Really good access … considering that nowadays health care has gone wrong and professionals don’t have time to do anything, but she has time and you can really speak your mind.” (Participant 3)
The participants expressed how their trusting relationships with the case managers resulted in the possibility to reflect on their current concerns. One of the participants expressed it as the case managers being able to provide them with a different viewpoint regarding their concerns. Thus, they were able to widen their own perspectives concerning parts of the health system:
“It’s always good to talk to somebody who can take a broader perspective than I can as I’m in the middle of it. I’m sort of unable to see the whole.” (Participant 13)
For some of the participants, these trusting relationships meant that they could more honestly communicate about how they felt, in contrast to the communication with their own family members:
“You dare say how you feel, which you can’t really do with the children, or they don’t understand, don’t take it in, but say … that’s good, you can, you’ll cope, you’ll manage.” (Participant 3)
During participant observations findings illustrated in the theme were observed. During observations same personal traits being expressed by the participants were observed and also a willingness amongst the case managers to sit down, take their time and talk about everyday life such as family situation, leisure activities or just the weather. During their conversations the case managers often tried to turn negative situations experienced by the participants into more positive situations, whilst trying to motivate the older persons to come up with feasible solutions for their current challenges.
Someone assisting me
The participants described how the case managers provided assistance to them in numerous ways: by mediating health and social care contacts, investigating their concerns, giving advice, as well as assisting them in making sense of parts of the health system. They commented on how the case managers were readily available and capable of assisting them with their current concerns. They spoke about how the case managers assisted them in navigating parts of the health system:
“She told me where to seek help and where to phone.” (Participant 11)
They further described how the case managers asked them numerous questions. These questions involved different subjects concerning their current health situation, disease status, current life satisfaction and current medications. They were asked if they needed any assistance as they raised concerns during the questioning. They were also asked by the case managers how they perceived their current contacts with the health and social care service providers:
“Yes, and then she wants to know what I think and if I’m satisfied with the service I get.” (Participant 6)
At times, the participants’ family members were present during their interactions with the case manager. They believed that their family members benefitted from the case managers as they also received information concerning the health system. Many of the participants did not find it difficult to seek assistance from the case managers; instead this was described as being a positive experience:
“You feel very welcome, I mean … it never feels awkward … no, no, you feel you can turn to her about anything and she has said as much, just phone if you’ve got something on your mind.” (Participant 3)
The participants were provided with different types, both oral and written, of information. The written information consisted of leaflets containing information on where to seek the required help. They often did not read these leaflets but rather viewed them as being a useful resource in the event that something happened to them. The oral information could consist of any information related to the health system. They described how they believed the case managers to be knowledgeable about different aspects concerning the health system. If there was something they could not understand, for instance if they received a complicated letter, they noted the opportunity to call the case managers for assistance:
“If there’s something I don’t understand. Because sometimes the written information you get can be a bit complicated. You only understand the half of it.” (Participant 1)
The participants were assisted by the case managers to mediate between different health and social care contacts. They were often instructed how they themselves should proceed with different tasks in order to get the necessary help, for example receiving contact information from the case managers with which they could contact specific health professionals. At times, the case managers took on more active roles, subsequently performing the necessary tasks for the participants by themselves e.g. aiding the participants by first investigating their current concerns. Afterwards, the case managers reported back to the participants with the updated information:
“They took samples and suchlike and … a long time passed but I heard nothing, then she phoned and asked them, yes she did. So I finally got an answer.” (Participant 11)
Findings from the interviews were also presented during participant observations. For instance, the participants expressed being asked a lot of questions by the case managers. Observations showed that the case managers used a questionnaire asking the participants questions regarding their current health situation. The questionnaire was delivered orally and was of help in bringing forth current health needs amongst the participants, as they had to articulate their answers. It was also observed how the case managers by actively listening to the older person’s conversation whilst regularly asking follow-up questions were able to identify health needs.
Someone who is on my side
The participants stated that the case managers were someone who stood on their side, being their own representative in their different struggles with health and social care representatives. They appreciated the case managers’ abilities to advocate for them at those times they felt mistreated. They expressed appreciation that the case managers clearly understood the importance of their concerns and did not belong to any organisations directly involved in their care. At those times when the participants were dissatisfied with their health and social care services e.g. the community health services provided, they were able to contact the case managers. The participants were then provided with information regarding their legal rights and how they could proceed on the matter. One of the participants described it as getting a honest opinion from the case managers. This was in contrast to the information given to him/her by staff and managers of the municipalities:
“… all your rights, because they don’t tell you about them. Take the representatives of the municipality, they don’t tell you about your rights. They keep quiet about them. You have to find out yourself.” (Participant 1)
The participants described how the case managers at times helped them to write reports regarding experienced incongruities in certain health and social care situations. They were also helped by the case managers to follow up on the progress of those reports. The participants stated that they got a more honest opinion from the case managers since they were not seen as being representatives of any health or social care organisations. Instead, they were viewed as being on the participants’ side:
“She’s on my side and she helps me.” (Participant 13)
The participants were advised by the case managers of what they perceived to be the best options for them. They sometimes admonished different interventions to the participants e.g. argued with the participants that they really should initiate contact with a health professional. The participants viewed this admonishing as a considerate act on the part of the case managers since they thought the case managers acted in their best interests. The participants also perceived the case managers to emphasise that the final decision should be their own and not anyone else’s:
“But, as I say, it’s a difficult decision and it’s up to me to decide, that’s what she always tells me.” (Participant 2)
The participants expressed an appreciation for how the case managers were able to step up and advocate for them when they felt mistreated by health professionals. One participant acknowledged this ability to advocate for him/her:
“And then I noticed that she was capable, wasn’t afraid, didn’t hesitate to approach anyone. And that’s a really good thing.” (Participant 10)
The participant observations reflected the interviews and it was observed how the older persons received confirmation by the case managers in a way that they were entitled to express their complaints. Furthermore, they were encouraged to express their complaints to those health and social care representatives involved in their care. A specific situation where the current theme was observed was during a care planning meeting at a hospital ward. An older man was planned to be discharged from the hospital to his apartment where he lived alone. Present at the meeting besides the older man were his three children, one nurse working at the ward, a home care organiser and a case manager. During the meeting it was observed that the persons around the older man was talking about and planning his upcoming home situation whilst more sporadically asking the older man about his views. In this situation the case manager regularly changed the focus of the conversation to the older man, both asking for his personal views on those aspects being discussed, advocating for the older man needs as well as positioning the conversation around the older persons own needs. This strategy was employed throughout the meeting and allowed the older man to be more in focus and to more fully express his opinions concerning his forthcoming home situation.
Someone I do not need at present
Some of the participants stated that they currently had no use of the services provided by the case managers. They spoke about how they did not have any concerns serious enough to ask the case managers for assistance. They acknowledged that the case managers could be of use in the future if their health status was to worsen. Some of the participants were also content managing their current concerns regarding health and social care by themselves or with the assistance of their relatives:
“No, I’ve had no need … because I’ve been able to manage many things myself and then my children have done them. So I haven’t needed to ask for her help.” (Participant 11)
A few of the participants narrated that they did not want to use the case managers’ services as they wanted to manage by themselves, even though they had some concerns. They described it as them being stubborn or that they already knew how they should proceed with their concerns. One of the participants described it as not wanting to become lazy by starting to ask for assistance from the case managers:
“Of course it’s easier when you don’t have to do it yourself … laughing … Then the laziness in me gains the upper hand. So that may be the case.” (Participant 8)
Other participants described how they were not in need of the case managers’ assistance since they were currently satisfied with the provided health and social care services and therefore did not know what the case managers could do for them:
“I have the home help service and they accompany me to the hospital and any health and dental care I need and I don’t need a case manager for other things.” (Participant 12)
Some of the participants viewed their contact with the case managers as being more of an insurance for the future, in case problems were to arise later on. They expressed an acknowledgement that if they were to be in worse condition later i.e. less clear-headed or having no relatives taking care of them, the case managers could then be of use to them:
“It could be something that you might need later on. We’re aware that we know nothing about tomorrow, what it’ll be like.” (Participant 8)
During participant observations the older persons’ willingness to manage by themselves or with the help of their family members was observed. Despite, displaying a willingness to manage by themselves, they also expressed appreciation when being offered assistance by the case managers.