Integrated care for adults with complex needs: opportunities of case management in primary care to improve equity

Context: Case management in primary healthcare has been documented as a promising integrated care approach to overcome fragmented care faced by adults with complex healthcare and social needs (hereafter complex needs). This approach could be an opportunity to better address social determinants of health and improve health equity for this population.

Objective: The aim of this study is to better understand how case management may address social determinants of health of people with complex needs.

Study Design: Qualitative descriptive multiple case study.

Setting/Population studied/Intervention: A case management program (CMP) for people with complex needs was implemented in four primary care clinics of an urban area.

Methods: Semi-structured interviews and focus groups with key informants (n=26) recruited through purposeful sampling were conducted, and participant observation was carried out during implementation committee meetings (n=31). All qualitative data were included in the inductive thematic analysis to identify themes related to social determinant of health. Research team members were involved in key steps of the analysis in an iterative process.

Results: The CMP encouraged the case managers and other healthcare providers to better understand people’s social needs by evaluating their whole situation more broadly. Having more consultation time and establishing a relationship of trust with people helped to address their unmet social needs. Social workers who collaborated in dyad with nurse case managers helped in identifying patients’ mental health issues as well as unmet social needs, e.g. poor-quality housing, social isolation, and difficulty affording transportation, or food. Creating community partnerships may help to overcome the limited capacity of case managers in assisting patients in their personal or administrative procedures, e.g. employment, immigration, or housing. However, partnerships between primary care clinics and community-based organizations would deserve consideration in further research.

Conclusions: Case management in primary healthcare may help better address social determinants of health and improve health equity by providing more dedicated time with these people, by improving interdisciplinary and intersectoral collaboration, and by improving social support. Future research should explore ways to enhance partnerships between healthcare providers and community organizations.