Table 5. Details of interventions.

Study	Name of case management model	Intensity of intervention (patient contacts)	Risk Assessment Tool (judgement/threshold/predictive risk modelling)	MDT or single case manager (primary case manager in bold)	Primary location of case management	24-hour availability of case manager	Caseload per manager/ team	Training received by case manager	Case management reimbursement method
Beland 2006a [57]; Beland 2006b [58]	SIPA [French acronym for System of Integrated Care for Older Persons]	Not clear	Threshold Functional Autonomy Measurement System (SMAF)	MDT: nurse/social worker, community nurses; occupational therapists, homemakers, staff family physicians, (consultant pharmacists), (community organisers)	Not clear	Yes	35–45	Yes	Family physician offered $400 per SIPA patient in addition to their usual FFS
Bernabei 1998 [59]	Integrated community care	Every 2 months	Threshold previous use of home services	MDT: trained case manager, general practitioner, geriatrician, social worker, nurses	Not clear	Not clear	Not clear	Yes	Not clear
Bird 2010 [60]	HARP [Hospital Admission Risk Programme]	4–7 times in 12 months	Threshold previous hospital use	MDT: trained case facilitator, N/S	Home	Not clear	Not clear	Unclear	Not clear
Boult 2008 [61]; Leff 2009 [62]; Boyd 2010 [63]; Boult 2011 [64]; Boult 2013 [65]	Guided care	Monthly	Predictive risk modelling Hierarchical Condition Category (HCC)	MDT: Nurse, physicians	Not clear	Not clear	50–60	Yes	FFS
Boyd 1996 [66]	Community-based case management	Averaged 4.45 hours per patient per month	Threshold previous secondary care use	Single: nurse	Home	Not clear	Not clear	Unclear	Not clear
Burns 1995 [67]; Burns 2000 [68]	GEM [Geriatric Evaluation and Management]	Not clear	Threshold mixture of criteria judging frailty	MDT: GEM team (physician, nurse, social worker, psychologist)	GEM clinic	Not clear	Not clear	Yes	Not clear
Coburn 2012 [69]	Community-based nursing intervention	Minimum of monthly. Average 17.4 contacts per patient per year	Predictive risk modelling Sutter Health Questionnaire/numeric risk score	Single: nurse	Various	Not clear	85–110	Yes	FFS + fixed fee per participant per month
Counsell 2007 [70]; Counsell 2009 [71]	GRACE [Geriatric Resources for Assessment and Care of Elders]	Minimum of monthly	Threshold income level	MDT: nurse/social worker, geriatrician, pharmacist, physical therapist, mental health social worker, community-based services liaison	Home/ telephone	Not clear	Not clear	Unclear	Not clear
Dalby 2000 [72]	Visiting nurse	Not clear	Threshold Questionnaire (functional impairment/past hospital use)	Single: nurse	Home	Not clear	Not clear	Unclear	Capitation
De Stampa 2014 [73]	COPA [CO-ordinationPersonnesAgées]	Not clear	Threshold Contact Assessment (CA) tool	MDT: Nurse, primary care physician, (geriatrician)	Home	Not clear	40	Yes	Not clear
Dorr 2008 [74]	CMP [Care Management Plus]	Not clear	Judgement clinical judgement	Single: nurse	Not clear	Not clear	Not clear	Yes	Not clear
Enguidanos 2006 [75]	Kaiser Permanente Community Partners	TCM: 4–5 contacts per patient per 4-week period GCM: Approx 20 hours per case over 8–9 months	Threshold functional/utilisation criteria	TCM- Single: social worker GCM- MDT: nurse/social worker, geriatrician, assistant department manager	TCM: Telephone GCM: Home/ telephone	Not clear	Not clear	Unclear	Not clear
Fan 2012 [76]	CCMP [Comprehensive Care Management Program]	Monthly for 3 months. Every 3 months thereafter.	Threshold previous hospital use	Single: healthcare professional(qualification varied by site)	Telephone	No	Not clear	Yes	Not clear
Fitzgerald 1994 [77]	GMC [General Medicine Clinic] case management	Averaged 1.6 per patient per month	Threshold previous hospital use	Single: nurse	Clinic/ Telephone	Yes	Not clear	Unclear	Salaried nurse
Fordyce 1997 [78]	STAR [Senior Team Assessment and Referral programme]	Not clear	Threshold STAR questionnaire (measuring frailty)	MDT: nurse, geriatrician, health educator, geriatric psychiatrist	Telephone	Not clear	Not clear	Unclear	Not clear
Gagnon 1999 [79]	Community-based nurse case management	Minimum monthly call, and home visit every 6 weeks.	Predictive risk modelling Boult assessment tool (40% or more probability of hospitalisation)	Single: nurse	Home/ telephone	No	40–55	Yes	Not clear
Gravelle 2007 [80]	Evercare	Not clear	Threshold previous emergency admissions	Single: nurse	Not clear	Not clear	Not clear	Unclear	Not clear
Hogg 2009 [81]; Gray 2010 [82]	APTCare [Anticipatory and Preventive Team Care]	Not clear	Judgement clinical judgement	MDT: nurse, pharmacist, usual family physician	Home	Not clear	Not clear	Yes	FFS/ capitation
Kruse 2010 [83]	Nurse care coordination	Not clear	Threshold previous outpatient use	Single: nurse	Clinic/ telephone	Not clear	Not clear	Unclear	Not clear
Leung 2004 [84]	Case Management Project	Once every two weeks.	Threshold previous hospital use	MDT: nurse/social worker, geriatricians, senior social workers, geriatric nursing specialist, clinical psychologist, rehabilitation therapists	Home/ telephone	Not clear	Not clear	Unclear	Not clear
Levine 2012 [85]	CHA [Choices for Healthy Aging]	Minimum monthly	Predictive risk modelling electronic risk assessment tool	MDT: team (physician, nurse practitioner, nurse care manager, social worker)	Home/ telephone	Yes	Not clear	Unclear	Not clear
Martin 2004 [86]	Care plans for COPD	Visits at 0, 3, 6, and 12 months.	Threshold previous COPD exacerbations requiring care	MDT: nurse, respiratory specialist, GP	Not clear	Not clear	Not clear	Unclear	Not clear
Metzelthin 2013[87]	PoC [Prevention of Care]	Not clear	Threshold Groningen Frailty Indicator	MDT: nurse, GP, (occupational therapist), (physical therapist), (other health professionals as needed)	Home	Not clear	Not clear	Yes	Not clear
Morishita 1998 [88]; Boult 2001 [89]	GEM [Geriatric Evaluation and Management]	Monthly clinic visits + telephone availability	Predictive risk modelling probability of repeated admission instrument	MDT: GEM team (geriatrician, geriatric nurse practitioner, nurse, social worker)	GEM clinic/ telephone	Yes	Not clear	Unclear	FFS
Newcomer 2004 [90]	ECM [Enhanced Case Management]	Minimum monthly. Weekly until problem resolution. Average 7.7 hours per patient over 12 months.	Threshold presence of chronic conditions (subsequently stratified by risk score obtained from assessment questionnaire)	Single: nurse	Telephone	Not clear	250 (~60 actively case managed at any time)	Unclear	Not clear
Ploeg 2010 [91]	Preventive primary care outreach	Minimum 3 yearly visits + follow-up phone calls/home visits.	Threshold Sherbrooke postal questionnaire (assessing risk of functional decline)	Single: nurse	Home/ telephone	Not clear	Not clear	Unclear	Capitation-based that includes some FFS
Rodenas 2008 [92]	Case management Valencia	Minimum once every 2 months.	Judgement referral protocol of social and health cases	MDT: team (physician, nurse, social worker)	Not clear	Not clear	Not clear	Yes	Not clear
Rubenstein 2007 [93]	Screening, case finding, referral	One month after first contact. Every 3 months thereafter.	Threshold Geriatric Postal Screening Survey	Single Physician assistant	Telephone	Not clear	Not clear	Unclear	Not clear
Schraeder 2001 [94]	Collaborative primary care nurse case management	Average 8 contacts per patient per year.	Judgement/ Threshold clinical judgement/presence of determined risk factors	MDT: nurse/case assistant, primary care physician	Various	Not clear	Not clear	Unclear	Not clear
Schraeder 2008 [95]	Collaborative primary care nurse case management	Minimum monthly	Threshold health screening questionnaire	MDT: nurse, case assistant, primary care physician	Various	Not clear	Not clear	Unclear	Not clear
Shannon 2006 [96]; Alkema 2007 [97]	Care Advocate Programme	Minimum monthly	Predictive risk modelling health care utilisation algorithm	Single: social worker	Telephone	Not clear	Not clear	Unclear	Not clear
Sledge 2006 [98]	PIC [Primary Intensive Care]	Minimum monthly	Threshold previous hospital use	MDT: psychiatric nurse, social worker, psychiatrist, general internist	Telephone	Not clear	21	Unclear	Not clear
Stuck 2000 [99]	In-home visits for disability prevention	Every 3 months.	Threshold Scoring on 6 criteria generated from the literature	Single: nurse	Home	Not clear	Not clear	Yes	Not clear
Sylvia 2008 [100]; Boyd 2008 [101]	Guided care	Minimum monthly	Predictive risk modelling Adjusted Clinical Groups Predictive Model	MDT: nurse, primary care physician	Not clear	Not clear	50–60	Yes	Capitated insurance system
Toseland 1996 [102]; Toseland 1997 [103]; Engelhardt 1996 [104]; Engelhardt 2006 [105]	GEM [Geriatric Evaluation and Management]	Not clear	Threshold previous outpatient use + functional impairments	MDT: nurse, geriatrician, social worker	GEM clinic	Not clear	Not clear	Unclear	Not clear
van Hout 2010 [106]	Nurse home visits	Minimum 4 visits per patient per year	Threshold frailty score (COOP-WONCA charts)	Single: nurse	Home	Not clear	Not clear	Yes	Not clear