Better care for people with complex care needs: a partnership between primary care clinics and the community network

Context: Patients with complex health and social care needs face significant service coordination and integration issues. They often require a variety of services from different programs and the community network. A case management program (CMP) for patients with complex care needs was implemented in primary care clinics to improve services coordination with community resources and integrated health and social services centers.

Objective: Identify factors facilitating or hindering: 1) the implementation of the CMP in primary care clinics; and 2) interactions with community resources.

Study Design and Analysis: A qualitative descriptive multiple case study using an inductive thematic analysis approach.

Setting or Dataset: Four clinics in an urban area of the province of Quebec (Canada), where the CMP was implemented.

Population Studied: Key informants (n=36) involved in the implementation of the CMP: 2 implementation project managers, 4 clinic managers, 1 case manager from an integrated health and social services center, 8 case managers in primary care clinics, 4 physician leads, and 5 other healthcare professionals. Method: Semi-structured interviews and focus groups with key informants, and participant observation (n=12 hours) during executive meetings.

Outcome Measures: Themes that emerged from the inductive thematic analysis.

Results: The active support of an experienced case manager from the integrated health and social center, the participation in a community of practice, and the collaboration between social workers and nurses, helped case managers to engage, gain confidence in performing new tasks and be aware of community resources. The density of services in the urban area presented advantages in terms of various services adapted to the patient’s needs but also raised care coordination challenges for patients who use multiple services over a wide area. More interaction between internal and external partners would have been useful in monitoring the implementation process, particularly with family physicians. Limited access to mental care services may hinder the engagement of case managers, especially with patients with important mental health challenges.

Conclusions: This study informs policy makers, clinicians, and researchers on levers and pitfalls to avoid in the implementation of complex interventions such as CMP for patients with complex care needs in primary care settings.