The Relationship Between Traumatic Injury in Children and Long-Term Use of Health and Social Services by Children and Their Families.

To increase understanding of relationships between general traumatic injury in children and long-term use of resources in the health care and social services (HSS) sectors by these children and their families 8-10 years after traumatic injury. This study was a cross-sectional retrospective cohort study of prognosis from 2001 to 2003 that quantified recent expenditures on and use of HSS by children and also by their parents. Forty-eight cases of children were selected from the Hamilton Health Sciences pediatric trauma database in the period from January 2001 to December 2003 after incurring a traumatic injury with Injury Severity Score greater than 12. The average total cost to the HSS system per child's family was $4,326.62 during the preceding 6 months. During the same period, average use of HSS was 7 visits. Total service costs incurred by caregivers of injured children increased with severity of the traumatic injury (p= .009). Caregiver HSS use was higher when the injury was caused by a motor vehicle accident than by other types of accidents (p< .001) and increased with the injury severity (p< .001). HSS use by children was related to gender (p< .001), injury mechanism (p< .001), age at accident (p< .001), and time since accident (p= .012), among other factors. Pediatric trauma appears to have long-term effects on expenditures on and use of HSS by the affected children and their families. The findings emphasize the need for long-term assessment and possible delivery of services to the families of the injured children.

Age-dependent changes in Porphyromonas gingivalis and Prevotella species/phylotypes in healthy gingiva and inflamed/diseased sub-gingival sites.

OBJECTIVES: Early colonisation of oral surfaces by periodontal pathogens presents a significant risk factor for subsequent development of destructive disease affecting tissues that support the dentition. The aims of the present study were to establish the age-dependent relationship between sub-gingival profiles of 22 Prevotella species/phylotypes in children, adolescents and adults from an isolated Aboriginal community and, further, to use this information to identify Prevotella species that could serve as microbial risk indicators. MATERIALS AND METHODS: DNA isolated from sub-gingival plaque samples (three healthy sites and three inflamed/diseased sites) from adults, adolescents and children was screened for Porphyromonas gingivalis load and 22 Prevotella species/phylotypes by species-specific PCR. RESULTS: A noticeable feature in adolescents was the marked increase in colonisation by P. gingivalis across all test sites. The mean number of Prevotella species/phylotypes colonising inflamed/diseased sub-gingival sites increased with age. Progressive partitioning of selected Prevotella species/phylotypes to healthy or inflamed/diseased sites was evident. Prevalence of Prevotella intermedia, Prevotella oral clone P4PB_24 and Prevotella oris increased significantly with age in diseased sites. Similarly, significant age-dependent increase in colonisation of healthy as well as inflamed/diseased sub-gingival sites was apparent for Prevotella oralis, Prevotella multiformis, Prevotella denticola, Prevotella strain P4P_53 and Prevotella oral clone BR014. CONCLUSION: Early colonisation of children by P. gingivalis, P. intermedia and Prevotella oral clone P4PB_24 provides indication of risk for subsequent development of periodontal disease. CLINICAL RELEVANCE: In the present study, the complexity of Prevotella species within gingival sites is explored as a basis for evaluating contribution of Prevotella species to disease.

Better Care and Better Value for Canadians: A Review of RCT Studies of Nurse Interventions.

This review is focused on the effectiveness of nursing interventions for patient outcomes and healthcare costs. It was guided by ecological and economic evaluation frameworks. Restricting the first-tier search of over 4,000 articles to randomized controlled trials (RCTs) yielded 203 studies and 9 additional trials that used identical methods of cost evaluation. Of 212 RCTs, 37 met the eligibility criteria. Of the 37 articles, 29 came from the literature search and 8 came from the first author's research unit, which used identical methods of economic evaluation. Of the first 29 studies, 26 found that nurse interventions were more or equally effective and less or equally costly compared to usual care, as was true of 7 of the 9 RCTs with comprehensive economic evaluations. It is effective and efficient to deploy specialty-trained nurses to lead teams of professionals, including physicians, assembled to address complex patient needs. A nurse-led model of proactive and supplemental care for the chronically ill, versus the on-demand, physician-led model now in place, would be more or equally effective and less or equally costly.

La présente revue porte sur l'efficacité des interventions infirmières en ce qui concerne les résultats pour les patients et les coûts liés aux soins. Sa réalisation a été orientée par un cadre d'évaluation économique et écologique. Restreinte aux essais cliniques randomisés, la première étape de la recherche, effectuée à partir d'un bassin de plus de 4 000 articles, a permis de dégager du lot 203 études et 9 essais cliniques supplémentaires utilisant des méthodes identiques d'évaluation des coûts. Sur ces 212 études et essais, 37 répondaient aux critères d'admissibilité, et parmi ces 37 articles admissibles, 29 provenaient du dépouillement de la littérature et 8 de l'unité de recherche de la première auteure, qui utilise exactement les mêmes méthodes d'évaluation économique. Dans le groupe des 29 premières études, 26 constataient une efficacité des interventions infirmières égale ou supérieure aux soins réguliers pour un coût égal ou inférieur, constatation également présente dans 7 des 9 essais cliniques randomisés ayant fait l'objet d'une évaluation économique approfondie. Il est donc efficace et rentable de déployer du personnel infirmier spécialisé pour diriger des équipes de professionnels, y compris les médecins, mises sur pied pour donner des soins aux patients ayant des besoins complexes. Ainsi, pour les patients souffrant de maladies chroniques, un modèle de soins proactifs supplémentaires dirigé par du personnel infirmier serait, par rapport au modèle actuel de soins sur demande dirigé par des médecins, plus efficace ou également efficace, et ce, pour un coût égal ou inférieur.

An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms.

BACKGROUND: Depressive symptoms in older home care clients are common but poorly recognized and treated, resulting in adverse health outcomes, premature institutionalization, and costly use of health services. The objectives of this study were to examine the feasibility and acceptability of a new six-month interprofessional (IP) nurse-led mental health promotion intervention, and to explore its effects on reducing depressive symptoms in older home care clients (≥ 70 years) using personal support services. METHODS: A prospective one-group pre-test/post-test study design was used. The intervention was a six-month evidence-based depression care management strategy led by a registered nurse that used an IP approach. Of 142 eligible consenting participants, 98 (69%) completed the six-month and 87 (61%) completed the one-year follow-up. Outcomes included depressive symptoms, anxiety, health-related quality of life (HRQoL), and the costs of use of all types of health services at baseline and six-month and one-year follow-up. An interpretive descriptive design was used to explore clients', nurses', and personal support workers' perceptions about the intervention's appropriateness, benefits, and barriers and facilitators to implementation. RESULTS: Of the 142 participants, 56% had clinically significant depressive symptoms, with 38% having moderate to severe symptoms. The intervention was feasible and acceptable to older home care clients with depressive symptoms. It was effective in reducing depressive symptoms and improving HRQoL at six-month follow-up, with small additional improvements six months after the intervention. The intervention also reduced anxiety at one year follow-up. Significant reductions were observed in the use of hospitalization, ambulance services, and emergency room visits over the study period. CONCLUSIONS: Our findings provide initial evidence for the feasibility, acceptability, and sustained effects of the nurse-led mental health promotion intervention in improving client outcomes, reducing use of expensive health services, and improving clinical practice behaviours of home care providers. Future research should evaluate its efficacy using a randomized clinical trial design, in different settings, with an adequate sample of older home care recipients with depressive symptoms. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01407926.

pH gradient and distribution of streptococci, lactobacilli, prevotellae, and fusobacteria in carious dentine.

OBJECTIVES: Caries process comprises acidogenic and aciduric bacteria that are responsible for lowering the pH and subsequent destruction of hydroxyapatite matrix in enamel and dentine. The aim of this study was to identify the correlation between the pH gradient of a carious lesion and proportion and distribution of four bacterial genera; lactobacilli, streptococci, prevotellae, and fusobacteria with regard to total load of bacteria. MATERIALS AND METHODS: A total of 25 teeth with extensive dentinal caries were sampled in sequential layers. Using quantitative real-time PCR of 16S rRNA gene, we quantified the total load of bacteria as well as the proportion of the above-mentioned genera following pH measurement of each sample with a fine microelectrode. RESULTS: We demonstrated the presence of a pH gradient across the lesion with a strong association between the quantity of lactobacilli and the lowest pH range (pH 4.5-5.0; p = 0.003). Streptococci had a tendency to occupy the most superficial aspect of the carious lesion but showed no correlation to any pH value. Prevotellae showed clear preference for the pH range 5.5-6.0 (p = 0.042). The total representation of these four genera did not reach more than one quarter of the total bacterial load in most carious samples. CONCLUSION: We revealed differential colonization behavior of bacteria with respect to pH gradient and a lower than expected abundance of lactobacilli and streptococci in established carious lesions. The data indicate the numerical importance of relatively unexplored taxa within the lesion of dentinal caries. CLINICAL RELEVANCE: The gradient nature of pH in the lesion as well as colonization difference of examined bacterial taxa with reference to pH provides a new insight in regard to conservative caries management.

The role of heme binding by DNA-protective protein from starved cells (Dps) in the Tolerance of Porphyromonas gingivalis to heme toxicity.

The widely expressed DNA-protective protein from starved-cells (Dps) family proteins are considered major contributors to prokaryotic resistance to stress. We show here that Porphyromonas gingivalis Dps (PgDps), previously described as an iron-storage and DNA-binding protein, also mediates heme sequestration. We determined that heme binds strongly to PgDps with an apparent K(d) of 3.7 × 10(-8) m and is coordinated by a single surface-located cysteine at the fifth axial ligand position. Heme and iron sequestered in separate sites by PgDps provide protection of DNA from H(2)O(2)-mediated free radical damage and were found to be important for growth of P. gingivalis under excess heme as the only iron source. Conservation of the heme-coordinating cysteine among Dps isoforms from the Bacteroidales order suggests that this function may be a common feature within these anaerobic bacteria.

Development of the oral resistome during the first decade of life.

Antibiotic overuse has promoted the spread of antimicrobial resistance (AMR) with significant health and economic consequences. Genome sequencing reveals the widespread presence of antimicrobial resistance genes (ARGs) in diverse microbial environments. Hence, surveillance of resistance reservoirs, like the rarely explored oral microbiome, is necessary to combat AMR. Here, we characterise the development of the paediatric oral resistome and investigate its role in dental caries in 221 twin children (124 females and 97 males) sampled at three time points over the first decade of life. From 530 oral metagenomes, we identify 309 ARGs, which significantly cluster by age, with host genetic effects detected from infancy onwards. Our results suggest potential mobilisation of ARGs increases with age as the AMR associated mobile genetic element, Tn916 transposase was co-located with more species and ARGs in older children. We find a depletion of ARGs and species in dental caries compared to health. This trend reverses in restored teeth. Here we show the paediatric oral resistome is an inherent and dynamic component of the oral microbiome, with a potential role in transmission of AMR and dysbiosis.

Interprofessional stroke rehabilitation for stroke survivors using home care.

OBJECTIVE: To compare a specialized interprofessional team approach to community-based stroke rehabilitation with usual home care for stroke survivors using home care services. METHODS: Randomized controlled trial of 101 community-living stroke survivors (<18 months post-stroke) using home care services. Subjects were randomized to intervention (n=52) or control (n=49) groups. The intervention was a 12-month specialized, evidence-based rehabilitation strategy involving an interprofessional team. The primary outcome was change in health-related quality of life and functioning (SF-36) from baseline to 12 months. Secondary outcomes were number of strokes during the 12-month follow-up, and changes in community reintegration (RNLI), perceived social support (PRQ85-Part 2), anxiety and depressive symptoms (Kessler-10), cognitive function (SPMSQ), and costs of use of health services from baseline to 12 months. RESULTS: A total of 82 subjects completed the 12-month follow-up. Compared with the usual care group, stroke survivors in the intervention group showed clinically important (although not statistically significant) greater improvements from baseline in mean SF-36 physical functioning score (5.87, 95% CI -3.98 to 15.7; p=0.24) and social functioning score (9.03, CI-7.50 to 25.6; p=0.28). The groups did not differ for any of the secondary effectiveness outcomes. There was a higher total per-person costs of use of health services in the intervention group compared to usual home care although the difference was not statistically significant (p=0.76). CONCLUSIONS: A 12-month specialized, interprofessional team is a feasible and acceptable approach to community-based stroke rehabilitation that produced greater improvements in quality of life compared to usual home care. Clinicaltrials.gov identifier: NCT00463229.

Reducing depression in older home care clients: design of a prospective study of a nurse-led interprofessional mental health promotion intervention.

BACKGROUND: Very little research has been conducted in the area of depression among older home care clients using personal support services. These older adults are particularly vulnerable to depression because of decreased cognition, comorbid chronic conditions, functional limitations, lack of social support, and reduced access to health services. To date, research has focused on collaborative, nurse-led depression care programs among older adults in primary care settings. Optimal management of depression among older home care clients is not currently known. The objective of this study is to evaluate the feasibility, acceptability and effectiveness of a 6-month nurse-led, interprofessional mental health promotion intervention aimed at older home care clients with depressive symptoms using personal support services. METHODS/DESIGN: This one-group pre-test post-test study aims to recruit a total of 250 long-stay (> 60 days) home care clients, 70 years or older, with depressive symptoms who are receiving personal support services through a home care program in Ontario, Canada. The nurse-led intervention is a multi-faceted 6-month program led by a Registered Nurse that involves regular home visits, monthly case conferences, and evidence-based assessment and management of depression using an interprofessional approach. The primary outcome is the change in severity of depressive symptoms from baseline to 6 months using the Centre for Epidemiological Studies in Depression Scale. Secondary outcomes include changes in the prevalence of depressive symptoms and anxiety, health-related quality of life, cognitive function, and the rate and appropriateness of depression treatment from baseline to 12 months. Changes in the costs of use of health services will be assessed from a societal perspective. Descriptive and qualitative data will be collected to examine the feasibility and acceptability of the intervention and identify barriers and facilitators to implementation. DISCUSSION: Data collection began in May 2010 and is expected to be completed by July 2012. A collaborative nurse-led strategy may provide a feasible, acceptable and effective means for improving the health of older home care clients by improving the prevention, recognition, and management of depression in this vulnerable population. The challenges involved in designing a practical, transferable and sustainable nurse-led intervention in home care are also discussed. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01407926.

Recovery-oriented service provision and clinical outcomes in assertive community treatment.

OBJECTIVE: While the term "recovery" is routinely referenced in clinical services and health policy, few studies have examined the relationship between recovery-oriented service provision and client outcomes. The present study was designed to examine the relationship between recovery-orientation of service provision for persons with severe mental illnesses and outcomes in Assertive Community Treatment (ACT). METHODS: Client, family, staff, and manager ratings of service recovery-orientation and outcomes across a range of service utilization and community functioning indicators were examined among 67 ACT teams in Ontario, Canada. RESULTS: Significant associations were found between ratings of recovery-oriented service provision and better outcomes in the domains of legal involvement, hospitalization days, education involvement, and employment. Results were not uniformly positive or consistent, however, across stakeholder Recovery Self-Assessment (RSA) ratings or outcomes. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings provide some preliminary support for an association between recovery-oriented service delivery for persons with severe mental illnesses and better outcomes. In line with the current practice commentary, this association would suggest the importance of evaluating and cultivating recovery-oriented values and practices in ACT contexts. This is a particularly salient point given that ACT standards minimally address key domains of recovery-oriented service provision. Further study is required, however, to determine if these findings apply to the implementation of ACT in other jurisdictions or generalize to other community support programs.

A comparative assessment of attendance and nonattendance at Camp Trillium by children with cancer and their families; including their utilization of health and social services.

BACKGROUND: Camping programs for children with chronic diseases are designed for specific needs, but rigorous evaluation of their impact is largely lacking. The biggest camp for children with cancer and their families provided an opportunity to conduct such an investigation. METHODS: The study sample consisted of 76 attendee and 86 non-attendee families. Parents and children completed a series of validated questionnaires addressing family functioning (the primary effect measure); health-related quality of life (HRQL) of the patients; the children's behavior and relationships; parental behavior, mood and social support; parental nurturance, rejection and monitoring (from the perspective of the children); and a health and social service utilization inventory. RESULTS: The most common diagnoses in the attendee and nonattendee groups were acute lymphoblastic leukemia and central nervous system tumors, respectively. A higher proportion of attendees were receiving active treatment (26.7% vs. 5.8%), almost all for relapsed disease. Parent attendees reported significantly better family function and social support, and parenting skills and coping, than nonattendee parents. The parental proxy assessments of the children's overall HRQL revealed significantly better scores for the attendees, although there was a greater burden of pain among attendees and of cognitive morbidity among nonattendees. Costs related to health care and social services were substantially greater in the attendee families. CONCLUSIONS: Children with cancer cannot be randomized not to attend camp. So the results of this study cannot resolve the conundrum--do better-adapted families attend a camp designed to meet the special needs of their children, or does attendance materially improve the health and welfare of families of children with cancer? However, the very proliferation of such camps is indicative of a need being met and greater efforts should be made to promote the camping experience, and to encourage such children and their families to participate.

Fidelity and recovery-orientation in assertive community treatment.

There has been increasing commentary about the degree to which Assertive Community Treatment (ACT) teams provide recovery-oriented services, often centered around the question of the use of coercion. The present study was designed to contribute to this discussion through an examination of recovery-oriented service provision and ACT fidelity among 67 teams in the province of Ontario, Canada. The findings indicated a moderate to high degree of recovery orientation in service provision, with no significant relationship between ACT fidelity and consumer and family/key support ratings of recovery orientation. A significant relationship was found, however, between the 'nature of services' domain of the Dartmouth Assertive Community Treatment Scale (DACTS) and ratings of recovery orientation provided by staff and ACT coordinators. These findings extend the existing dialogue regarding the evaluation of ACT intervention process factors and indicate that current measures of fidelity may not be adequately addressing dimensions of recovery-oriented service provision.

A cross-sectional study of the prevalence, correlates, and costs of falls in older home care clients 'at risk' for falling.

This study examined the six-month prevalence, risk factors, and costs of falls in older people using home support services who are at risk of falling. Of the 109 participants, 70.6 per cent reported >or= one fall in the previous six months, and 27.5 per cent experienced multiple falls. Although there was no statistically significant difference in any fall-related risk factor between fallers (1+ falls) and non-fallers (0 falls), fallers had clinically important trends towards lower levels of physical, social, and psychological functioning. There was no statistically significant difference between fallers and non-fallers in the total per-person costs of use of health services in the previous six months; however, there were significant differences between groups in specific types of health services. The multivariate analysis revealed the presence of five risk factors for falls: neurological disorder (e.g., cognitive impairment, Parkinson's disease), age >or= 85 years, environmental hazards, previous slip or trip, and visual impairment.

The effects and costs of a multifactorial and interdisciplinary team approach to falls prevention for older home care clients 'at risk' for falling: a randomized controlled trial.

This study determined the effects and costs of a multifactorial, interdisciplinary team approach to falls prevention. Randomized controlled trial of 109 older adults who are at risk for falls. This was a six-month multifactorial and evidence-based prevention strategy involving an interdisciplinary team. The primary outcome was number of falls during the six-month follow-up. At six months, no difference in the mean number of falls between groups. Subgroup analyses showed that the intervention effectively reduced falls in men (75-84 years old) with a fear of falling or negative fall history. Number of slips and trips was greatly reduced; and emotional health had a greater improvement in role functioning related to emotional health in the intervention group. Quality of life was improved, slips and trips were reduced, as were falls among males (75-84 years old) with a fear of falling or negative fall history.

Evaluating health-related quality of life and priority health problems in patients with prostate cancer: a strategy for defining the role of the advanced practice nurse.

A framework for the introduction and evaluation of APN roles emphasizes the importance of a systematic approach to role development based on the assessment of patient health needs. This study determined the health-related quality of life (HRQL) of patients with prostate cancer. The most frequent and severe patient health problems and their perceptions of priority health problems were identified and compared across five patient groups as a strategy to inform the supportive care role of the advanced oncology nurse for patients with advanced prostate cancer. The study found that the majority of men with early stage and advanced hormone sensitive prostate cancer can expect to enjoy good quality of life for several years following diagnosis. These two patient groups have common priority needs for improving their health related to sexual function, urinary frequency, urinary incontinence, and physical activity. Both groups may benefit from an advanced practice nursing (APN) role that can provide episodic supportive care for health problems occurring at different treatment stages. Conversely, it was found that men with advanced hormone refractory prostate cancer experience significantly poorer HRQL and have multiple severe health problems. These patients also have different priority needs including problems related to pain, fatigue, and decreased physical activity. Because of this, the focus of supportive care programs and interventions in advanced prostate cancer will differ for those with hormone refractory disease. They may benefit more from an APN role that can provide ongoing rather than episodic supportive care to assess and manage the multiple, new, and worsening health problems associated with progressive disease.

Lysine gingipain (kgp) biovars of Porphyromonas gingivalis exhibit differential distribution on oral mucosal sites.

A predominant kgp biovar colonized subgingival sites and buccal and tongue mucosa in 45 of 56 adults in an isolated community. The presence of biovars 381, W83, and W83v, but not HG66, correlated with the Porphyromonas gingivalis load at diseased sites. Biovars W83 and W83v poorly colonized tongue and buccal mucosa.

Preliminary study of the oral mycobiome of children with and without dental caries.

Children's oral health is in a dire state, with dental decay (caries) being one of the most common chronic diseases. While the role of bacteria in the oral microbiome and dental caries is established, the contribution of fungi is relatively unknown. We assessed the oral mycobiome in childhood (n = 17), to determine if the composition of fungi varies between children with and without caries. Oral mycobiome composition was assessed by using Illumina MiSeq to sequence the ITS2 region, which was amplified from dental plaque. This revealed that the oral mycobiome in the investigated children contained 46 fungal species. Candida albicans was the most abundant species and was ubiquitous in all samples, indicating this species may not be involved in caries development as previously suggested. While the overall diversity of fungi was similar, independent of caries status (p > 0.05), we found caries influenced the abundance of specific fungi. Children without caries had a significantly higher abundance of 17 species compared to children with caries, which had three enriched species (p < 0.001). While the differentially abundant species between health and caries may be specific to an Australian population, our findings indicate the mycobiome plays a role in oral health.

VMG II transport medium stabilises oral microbiome samples for Next-Generation Sequencing.

Next-Generation Sequencing is providing insights into the critical role of the oral microbiome in dental diseases. Application of this method can require the collection of dental plaque from large cohorts in field-type conditions, which necessitates a transport medium to preserve the microbiome composition. We evaluated the use of two transport media, VMG II and RNAprotect® Bacteria Reagent (Qiagen), for room temperature storage of dental plaque. VMG II has not previously been assessed for suitability to store microbiome samples intended for deep sequencing. We compared the microbiome composition of dental plaque (total n=23) stored in either VMG II or RNAprotect Bacteria at room temperature with immediately-frozen plaque. 454 sequencing of 16S gene amplicons was used to assess the plaque microbial composition. While the bacterial diversity recovered was similar between storage conditions (p>0.1), the abundance of bacteria was influenced by storage environment. Dental plaque stored in VMG II was most similar to immediately-frozen material, with only one of the 324 bacterial species being differentially abundant (Neisseria, p<0.001). In comparison, dental plaque stored in RNAprotect Bacteria had 24 differentially abundant species compared with the immediately-frozen samples and a significantly different phylogenetic structure (p<0.01). We have identified VMG II as a new transport medium for room temperature storage of dental plaque samples being subject to Next-Generation Sequencing that stabilises oral microbial DNA makeup.

A realist evaluation of value-based care delivery in home care: The influence of actors, autonomy and accountability.

The increasing demand for home care is occurring in tandem with the need for governments to contain health care costs, maximize appropriate resource utilization and respond to patient preferences for where they receive care. We describe the evaluation of the Integrated Client Care Project (ICCP), a government funded project designed to improve value for outcomes for patients referred to community wound care services in Ontario, Canada. We applied a realist evaluation methodology in order to unpack the influences of contextual and mechanistic choices on the intended outcomes of the ICCP implementation. We collected data through ethnographic methods including 36 months of field observation, 46 key informant interviews and contemporaneous document analysis. The findings presented here highlight how theoretical mechanisms were negatively impacted by strong contextual patterns and weak implementation which led to underwhelming outcomes. Autonomy of the participant organizations, lack of power within the implementation team to drive change, opacity of the goals of the program, and disregard for the impact of complex historical relations within the home care sector compounded to undermine the intended outcome.

Can we afford consumers choice in home care?

As demands for home care escalate in a system concerned with cost containments, initiatives promoting client involvement in the management oftheir chronic illnesses and attendant services have attracted increasing attention. For longer term in-home care, varied approaches to case management reflect these trends. This article reports a study exploring the cost consequences of clients' choice of three approaches to case management within a single home care context. The first involved leaving the control of services and care to the system's case manager. The second option was to share this control in partnership with their in-home service providers. The third approach featured clients directing their own case management Overall the average costs per month of services for clients in the three groups did not differ significantly over 6 or more months. However, clients who chose direct involvement in their case management actually had significantly lower cost increases than clients with little control over their case management. While further investigation is needed, offering clients choice of involvement in their in-home case management may both lower costs and optimize clients' potential for involvement in their care.