Case management of individuals with long-term conditions by community matrons: report of qualitative findings of a mixed method evaluation

A mixed-methods systematic review of nurse-led interventions for people with multimorbidity

AIMS

To identify types of nurse-led interventions for multimorbidity and which outcomes are positively affected by them.

DESIGN

Mixed-methods systematic review following the Joanna Briggs Institute (JBI) methods for convergent-integrated reviews.

PROSPERO ID

CRD42020197956.

DATA SOURCES

Cochrane CENTRAL, CINAHL, Embase and MEDLINE were searched in October 2020. Grey literature sources included OpenGrey, the Journal of Multimorbidity and Comorbidity and reference mining.

REVIEW METHODS

English-language reports of nurse-led interventions for people with multimorbidity were included based on author consensus. Two reviewers performed independent quality appraisal using JBI tools. Data were extracted and synthesized using a pre-existing taxonomy of interventions and core outcome set.

RESULTS

Twenty studies were included, with a median summary quality score of 77.5%. Interventions were mostly case-management or transitional care interventions, with nurses in advanced practice, support to self-manage conditions, and an emphasis on continuity of care featuring frequently. Patient-centred outcomes such as quality of healthcare and health-related quality of life were mostly improved, with mixed effects on healthcare utilization, costs, mortality and other outcomes.

CONCLUSION

Interventions such as case management are agreeable to patients and transitional care interventions may have a small positive impact on healthcare utilization. Interventions include long-term patient management or short-term interventions targeted at high-risk junctures. These interventions feature nurses in advanced practice developing care plans in partnership with patients, to simplify and improve the quality of care both in the long and short-term.

IMPACT

This is the first mixed-methods review which includes all types of nurse-led interventions for multimorbidity and does not focus on specific comorbidities or elderly/frail populations. Using adapted consensus-developed frameworks for interventions and outcomes, we have identified the common features of interventions and their overall typology. We suggest these interventions are of value to patients and healthcare systems but require localization and granular evaluation of their components to maximize potential benefits.

Patient experiences of integrated care within the United Kingdom: A systematic review

Introduction

Integrated care and patient experience are central to the coordination and delivery of high quality health and social care in the UK, but their joint application is poorly understood. This systematic review aimed to gain an understanding of patient experience within current integrated care services in the UK, and specifically, whether they reflect person-centred coordinated care (PCCC).

Methods

Following PRISMA, electronic databases (ProQuest, EBSCO and Cochrane Library) were searched from 2012 to 2019 for primary, peer-reviewed literature. Papers were included where patients’ or carers’ experiences of integrated care were reported. Papers were excluded where they focused on acute integrated care interventions, measured experience via satisfaction scores only, or findings lacked sufficient depth to answer the research question. Quality was assessed using Mixed Methods Appraisal Tool, and findings synthesised using a framework approach, incorporating the Rainbow Model of Integrated Care and Measuring Integrated Care Patient Framework.

Results

Sixteen studies were included. Person-centred and shared responsibility experiences were most often discussed. Experiences were not always described as positive and some patients experienced a lack of PCCC. Clinical, professional/organisational and functional integration processes were associated with experiencing domains of PCCC.

Discussion

People with complex needs experience a lack of coordination across teams and wider community resources, and limited associations were made between integration processes and patient experience. Further research which gives context to individual experience, provides greater detail of integration processes and utilises validated patient experience measures of PCCC is required to understand the association between integration processes and domains of PCCC.

Exploring a New Model of End-of-Life Care for Older People That Operates in the Space Between the Life World and the Healthcare System: A Qualitative Case Study

BACKGROUND

Innovative service models to facilitate end-of-life care for older people may be required to enable and bolster networks of care. The aim of this study was to understand how and why a new charitably funded service model of end-of-life care impacts upon the lives of older people.

METHODS

A multiple exploratory qualitative case study research strategy. Cases were 3 sites providing a new end-oflife service model for older people. The services were provided in community settings, primarily providing support in peoples own homes. Study participants included the older people receiving the end-of-life care service, their informal carers, staff providing care within the service and other stakeholders. Data collection included individual interviews with older people and informal carers at 2 time points, focus group interviews with staff and local stakeholders, nonparticipant observation of meetings, and a final cross-case deliberative panel discussion workshop. Framework analysis facilitated analysis within and across cases.

RESULTS

Twenty-three service users and 5 informal carers participated in individual interviews across the cases. Two focus groups were held with an additional 12 participants, and 19 people attended the deliberative panel workshop. Important elements contributing to the experience and impacts of the service included organisation, where services felt they were 'outsiders,' the focus of the services and their flexible approach; and the impacts particularly in enriching relationships and improving mental health.

CONCLUSION

These end-of-life care service models operated in a space between the healthcare system and the person's life world. This meant there could be ambiguity around their services, where they occupied a liminal, but important, space. These services are potentially important to older people, but should not be overly constrained or they may lose the very flexibility that enables them to have impact.

Patients' experiences of nurse case management in primary care: a meta-synthesis

The health system in New Zealand and Australia requires health practitioners to prepare for the challenge of long-term conditions. Wagner's 1998 Chronic Care Model advocates a move away from the traditional acute model of primary health care to a model that addresses the long-term episodic nature of chronic disease. Nurse case management has been developed over the last 2 decades as a means to coordinate health services for people with long-term conditions. This meta-synthesis combines the results of 15 qualitative research studies that have a similar research question regarding peoples' perceptions of nurse case management. The research synthesises the experiences of people with long-term conditions on the quality of care under a nurse case management model of primary health care. Over 1000 people were represented across the studies, and the results suggest that people had a high degree of confidence and trust in their nurse case manager, were better able to manage their health conditions with nurse case management support, and had better access to appropriate health care. This research suggests that nurse case management is an effective model of care and may contribute to improved quality of life and better health care for those with long-term health conditions.

Exploring the roles, functions, and background of patient navigators and case managers: A scoping review

BACKGROUND

Patient navigators and case managers are health care workers who aim to provide individualized assistance to patients facing significant health concerns. Although these roles emerged from distinct historical need, the terms are often used interchangeably in the literature and are described to have overlapping functions. Differences in the way that these roles are conceptualized across countries has led to a lack of clarity regarding the exact functions that each offer to patients, caregivers, and the health care system.

OBJECTIVES

To differentiate the functions and backgrounds of patient navigators and case managers across settings and disease contexts.

DESIGN

This review was guided based on the PRISMA extension for scoping reviews using a five-step review process: identify the research questions; search and identify relevant studies; select studies based on a priori criterion; chart the data; and collate, summarize and report the results.

DATA SOURCES

A search of the literature was undertaken in peer-reviewed databases (Medline, CINAHL, and PubMed) and the grey literature (Google and unpublished articles in online repositories).

REVIEW METHODS

Extracted data included information on patient navigators and/or case managers related to their reported background, training, and/or knowledge; roles and/or specific functions; clinical setting; and targeted condition or disease type.

RESULTS

The search strategy resulted in 10,523 articles. After applying the eligibility criteria during title and abstract evaluation, 468 full-text articles were reviewed, resulting in a total of 160 articles. Functions of patient navigators and case managers were organized into nine emerging categories: (1) advocacy; (2) care coordination; (3) case monitoring and patient needs assessment; (4) community engagement; (5) education; (6) administration and research activities; (7) psychosocial support; (8) navigation of services; and (9) reduction of barriers. The background and knowledge areas of each role were compared and contrasted, and three categories related to the practice context of each role were identified: (1) typical setting and care trajectory; (2) target patient population; and (3) mode of service delivery.

CONCLUSIONS

The current study identified important differences in the functions between patient navigators and case managers. However, there remains significant ambiguity between the functions of these two roles. Standardized definitions detailing scope of practice, and allowing for inherent flexibility across different settings, are needed to improve service delivery.

Community matrons as problem-solvers for people living with multi-co-morbid disease

Working with patients in their own homes gives community matrons an advantage of seeing patients in the context of their everyday lives. This allows comprehensive assessment of need with an aim of promoting health or promoting stability for people living with chronic disease. Complex issues are resolved through problem-solving and this can result in patients being maintained in their own homes and thus in reduced unplanned hospitalisation. Data were collected from participants using semi-structured interviews and audio diaries. The sample comprised professionals: CMs (n=21), managers (n=4), former commissioners (n=2) and GPs (n=3); and patients (n=10) and their family carers (n=5). In this article, data from community matrons is discussed. Community matrons often drew on the social determinants model of health to problem solve and to create meaningful strategies that work for patients in their care. Raising awareness of the high-level skills of community matrons and promoting appreciation of the importance of a social determinants model of health is important in explaining why nurses are such a crucial element of the primary health care workforce.

Applied research: building the evidence base for health sector development

Background:

Over recent years, there has been a growth of interest in applied research. With the continuing explosion in academically focused peer-reviewed publishing, researchers have been forced to reconsider the relevance of their work and its relationship to key health sector developments.

Contents:

In this article, we consider the nature of applied research—how does it differ from pure research, translational research, action research and/or monitoring and evaluation? We present a case study example drawn from a currently active area of applied research. We consider the fundamental questions that have to be considered by applied researchers: How can they retain methodological rigour?; Does he who pays the piper unduly call the tune?; Is the ‘opportunism’ of applied research compatible with ethical considerations?; Is an academic environment the most appropriate one in which to undertake applied research?

Conclusions:

The need for applied research has never been more pressing; yet executing it has never been more problematic. Notwithstanding the methodological and practical problems encountered, we argue that it plays a vital role in the development of health systems and of health systems researchers.

What is the role of a case manager in community aged care? A qualitative study in Australia

This study aimed to explore the perceptions of case managers about their roles in providing community aged care in Australia. Purposeful sampling was used and 33 qualitative semi-structured interviews with 47 participants were conducted. Participants were drawn from a list of all case managers working in aged care organisations that provided publicly funded case-managed community aged care programmes in the State of Victoria, Australia. Participant selection criteria included age, gender, job titles, professional backgrounds, practice locations, organisational attributes and organisational size. Data collection was implemented between September 2012 and March 2013. Thematic analysis was performed. Participants believed that case managers performed diverse roles based on clients' needs. They also articulated 16 important roles of case managers, including advisors, advocates, carers, communicators, co-ordinators, educators, empowering clients, engaging clients and families, liaising with people, managing budgets, navigators, negotiators, networking with people, facilitators, problem solvers and supporters. However, they were concerned about brokers, mediators and counsellors in terms of the terminology or case managers' willingness to perform these roles. Moreover, they perceived that neither gatekeepers nor direct service provision was case managers' role. The findings of this study suggest that case managers working in community aged care sectors may be more effective if they practised the 16 roles aforementioned. With the value of helping rather than obstructing clients to access services, they may not act as gatekeepers. In addition, they may not provide services directly as opposed to their peers working in medical care settings. The findings will also assist organisations to design job descriptions specifying case managers' roles and associated job responsibilities. Clear job descriptions will further benefit the organisations in staff recruitment, orientation and ongoing development, as well as facilitate case managers to set professional boundaries in the delivery of case management interventions to their clients.

'I can't walk away': understanding the complexities in embedding a new nurse role

BACKGROUND

The community matron (CM) role was introduced in England to provide a single point of access to patients living with comorbid long-term conditions who had, or were at risk of, frequent emergency hospitalisation.

AIM

This study explored the factors that affected embedding of the CM role. The qualitative study was undertaken in community health services in two cities and a rural area in central England.

METHOD

Participants comprised health professionals (n=30) including CMs, community service managers, and service commissioners; patients (n=10); and their family carers (n=5).

RESULTS

Findings reveal that participants were largely positive about the role. However, difficulties with role setup had led to numerous changes in service delivery, which affected how the role has embedded.

CONCLUSION

Many aspects of the CM role are invisible to other health professionals. Invisibility of community nursing, rather than autonomy of the CM role, seems to be a key factor in the challenges of embedding the role.

Case Management in Primary Care for Frequent Users of Health Care Services With Chronic Diseases: A Qualitative Study of Patient and Family Experience

PURPOSE

Although case management (CM) is increasingly being implemented to address the complex needs of vulnerable clienteles, few studies have examined the patient experience of CM. This study aimed to examine the experience of patients and their family members with care integration as part of a primary care CM intervention. Patients in the study were frequent users of health care services who had chronic diseases.

METHODS

A descriptive, qualitative approach was conducted involving 25 patients and 8 of their family members. Data were collected through in-depth interviews of the patients and 2 focus groups of family members and were analyzed thematically.

RESULTS

While some participants did not fully understand the CM intervention and a few believed that it involved too many appointments, the CM nurses were patients' preferred contact with primary care. The nurses actively involved the patients in developing and carrying out their individualized services plans (ISPs) with other health care partners. Patients felt that their needs were taken into consideration, especially regarding access to the health care system. The case manager facilitated access to information as well as communication and coordination among health care and community partners. This improved communication comforted the patients and nurtured a relationship of trust. Participants were actively involved in decision-making. Their ISPs helped them know where they were going and improved transitions between services.

CONCLUSIONS

The experience of patients and family members was overall very positive regarding care integration. They reported improved access, communication, coordination, and involvement in decision-making as well as better health care transitions.