Case management for individuals with complex care needs: Factors assisting and hindering implementation

Context: Case management (CM) is an effective intervention for patients with chronic conditions and complex care needs. While CM often leads to positive outcomes, it has rarely been implemented in primary care in Canada, and little is known of the factors which promote or hinder implementation.

Objective: To identify the factors which facilitated or hindered the implementation of CM in primary care from the perspective of nurse case managers, clinic managers and providers.

Study Design and Analysis: A secondary analysis of qualitative data from interviews and focus groups conducted throughout the PriCARE program (implementation analysis, telehealth sub-study and realist evaluation).

Setting: Primary care clinics in 4 jurisdictions in Canada (New Brunswick, Newfoundland and Labrador, Quebec, and Nova Scotia).

Population Studied: Key informants involved in the implementation of CM in primary care clinics: nurse case managers (NCMs); clinic managers and providers.

Intervention: A 12-month CM intervention including 4 components: patient needs assessment, care planning, coordination of services, and self-management support. This intervention was completed without additional clinic funding.

Outcome Measures: Key informant experiences of and reflections on CM implementation and researcher observations.

Instrument: Semi-structured interviews and focus groups with participants, as well as the reflections of the research team during the implementation process.

Results: Clinic factors which encouraged the implementation included a holistic collaborative team-based culture, an engaged and supportive clinic manager, the active involvement of care providers, and dedicated and protected time for NCMs to complete CM tasks. Lack of engagement from managers and physicians often led to low recruitment numbers and difficulty completing the intervention. NCMs who did not have set time in their schedules or who did not integrate the CM duties into their regular role struggled to carry out the program. Difficulty coordinating with specialists and external services also acted as a barrier. It was difficult for NCM’s to address individuals’ complex mental health needs due to lack of access to care.

Conclusions: The findings from this study provide insight into what worked well in implementing a 12-month CM intervention in a multi case study, as well as areas for improvement from the perspective of nurse case managers, clinic managers and providers.