Positive outcomes and limitations of a case management intervention in primary care for patients with complex care needs

Context: Growing evidence suggests that case management (CM) is an effective intervention to improve the care of patients with chronic conditions and complex care needs who are at risk for poorer health outcomes. While positive outcomes have been associated with CM in a range of settings and for a variety of patient populations, less is known about CMs potential when implemented in Canadian primary care settings for patients with complex care needs.

Objective: To identify positive outcomes and limitations of a CM program in primary care for patients with complex care needs. Study design: Secondary data analysis of realist evaluation data.

Setting: Seven primary care clinics across four provinces in Canada. Population studied: People with complex care needs.

Intervention: Twelve-month CM intervention led by nurse case managers (NCMs) in partnership with patients and other healthcare professionals consisting of four core components: 1) Patient needs assessment; 2) Care planning, including individualized services plan; 3) Care coordination; 4) Self-management support. Outcome measures: Program experiences and outcomes reported via realist interviews with patients (15), relatives (1), NCMs (6), providers (4), clinic managers (3) and other healthcare professionals (4) and analyzed thematically.

Results: Five themes represent the positive outcomes associated with the CM program: more appropriate and efficient use of health services (e.g., fewer emergency department visits), improved patient health and well-being (e.g., improved physical and mental health and health management), enhanced professional collaboration (e.g., communication between NCMs and providers), expanded professional practice (e.g., increased NCM knowledge and networks), and greater satisfaction for all stakeholders. CM limitations include limited availability of appropriate services and patient circumstances that impede their readiness to participate.

Conclusions: CM can positively affect patient satisfaction, health, and collaborative care in primary care settings by focusing on patient needs and goals and dedicating time and resources to coordinate care for patients with complex care needs. Patient circumstances and wider health system challenges may limit the effectiveness of CM for some.