Who cares for the oral health of dependent elderly and disabled persons living at home? : A qualitative study of case managers' knowledge, attitudes and initiatives

In 1999 a new law in Sweden granted people receiving a certain level of supportive care from the community the right to receive a free, in-home oral health assessment. Subsequent appraisal has disclosed that far from all eligible people, especially those living at home, have undergone such an assessment. Of fundamental importance to the success of this scheme is the active involvement of case managers in identifying those who are eligible for assessment. The aim of this study was to investigate case managers' knowledge of and attitudes to the oral health of their clients and the initiatives they take to ensure that dependent elderly and disabled persons living at home have access to oral health care. In qualitative in-depth interviews, 24 case managers from three Swedish counties were questioned about their perceptions of oral health care for their clients. The transcribed text was analysed by manifest and latent qualitative content analysis. The manifest analysis was based on the three content areas knowledge, attitudes and initiatives. During this process a theme emerged which disclosed the case managers' perceptions of their role in oral health care among elderly and disabled persons, a latent analysis. The case managers' age, education, experience and breadth of responsibilities varied. Their knowledge of the 1999 law was limited. In general there were no procedures in place to ensure that the oral assessments were undertaken and that records were kept. The case managers considered that they should not be responsible, although they could not suggest a more appropriate instance. The potential role of regular oral health assessment in prevention of oral diseases was not discussed at all in the interviews. The current systems for monitoring oral health are tailored primarily to institutionalised care. In future many more dependent people will continue to live at home with support from community home care assistants and relatives. It is important that oral health care activities, as well as research, are modified accordingly.