Case management in primary care for people with complex care needs: a realist evaluation

Context: Abundant literature supports case management (CM) as an intervention to improve care for people with complex care needs, but little explains how and why CM is effective, or not, in particular contexts.

Objective: To understand and explain how CM in primary care for people with complex care needs works, under what conditions and for whom.

Study design: Realist evaluation.

Setting: Seven primary care clinics across 4 provinces in Canada.

Population studied: People with chronic conditions and complex care needs.

Intervention: CM led by case managers in partnership with patients and other healthcare professionals according to four core components: 1) Patient needs assessment; 2) Care planning, including individualized services plan; 3) Care coordination; 4) Self-management support. Methods. Data collection: realist interviews with patients (n=13), case managers (n=6), clinic managers (n=3) and other healthcare professionals (n=8).

Analysis: Context (i.e. background of the intervention), mechanism (i.e. reasoning, attitudes and behaviors of stakeholders) and outcome (i.e. intervention impact) (CMO) were identified in a comprehensive table for each interview. CMO were then aggregated, organized and interpreted by the team. Regular discussions with the team helped to refine and validate the CMOs.

Results: Fourteen CMOs that demonstrate the mechanisms triggered to drive outcomes in particular contexts were identified. CM was most likely to be successful if all stakeholders were engaged in the intervention and felt supported by managers and colleagues. Moreover, positive patient effects were likely to be reported if trusting relationships were developed between patients and case managers. Differences in CM effectiveness across clinics were related to patient characteristics (motivation and complexity of healthcare needs), case manager characteristics (experience, background, skills and attitude) as well as organizational factors (access to care and external support, time and providers workload, team culture, and work location). Positive impacts on family members were also observed when they felt supported, respected, and accepted.

Conclusions: The realist evaluation offer context-sensitive explanations to better inform local practices and policies and to contribute to improved health of patients with complex care needs.