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

Patient Experiences and Perceptions of Care Coordination in Primary Care

BACKGROUND

Understanding patient perceptions of care coordination in primary care can help improve responsiveness to patients' needs, outcomes, and quality of care.

PURPOSE

The purpose of this study was to explore patient experiences and perceptions of care coordination in primary care.

METHOD

Interviews with 13 patients from 10 clinics were conducted and analyzed using directed content analysis.

RESULTS

Three primary themes arose: care coordinators provide a gateway to accessing needed care; patients needed and valued the support and trusted advice of their care coordinators; and patients valued care coordinators' help with navigating, engaging, and educating them about their care.

CONCLUSIONS

Understanding what patients value in care delivery can help frame a vision for a more responsive approach in delivering primary care, as well as create a pathway to quality improvement, moving toward a truly patient-centered focus in primary care.

Case managers within general practices in 11 Western countries: repeat cross-sectional studies

BACKGROUND

In the context of an ageing population and increasing health needs, primary care reform is needed and several new models have emerged, including the introduction of case managers in general practitioner practices.

AIM

To describe the frequency of case managers in general practices in eleven Western countries between 2012 and 2019 and to investigate the characteristics of general practitioners and their practices associated with case manager frequency.

METHODS

A secondary analysis of the Commonwealth Fund International Health Policy Surveys of Primary Care Physicians, which were international cross-sectional studies conducted in 2012, 2015 and 2019. Random samples of general practitioners were selected in 11 Western countries (2012: n = 9776; 2015: n = 12,049; 2019: n = 13,200). The use of case managers in general practitioner practices was determined with the question "Does your practice use personnel, such as nurses or case managers, to monitor and manage care for patients with chronic conditions that need regular follow-up care?", with possible answers "Yes, within the practice", "Yes, outside the practice", "Yes, both within and outside the practice" or "No". Other variables characterising general practitioners and their practices were considered. Mixed-effects logistic regression was performed.

RESULTS

The frequency of case managers within general practitioner practices varied greatly by country, with an overall trend towards an increase from 2012 to 2019. In the multivariate analysis, more case managers were found in practices located in small towns (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.2-1.7) and in rural areas (OR 1.9; 95% CI 1.5-2.4) compared to cities. The frequency of case managers was higher in larger practices, as shown in comparisons of practices in the second, third and fourth quartile of full-time equivalent employee counts compared to those in the first quartile (Q2: OR 1.7, 95% CI 1.4-1.9; Q3: OR 2.1, 95% CI 1.6-2.9; Q4: OR 3.8, 95% CI 3.0-4.9). There was no significant difference in frequency with respect to the age and sex of the general practitioners.

CONCLUSION

The use of case managers in general practitioner practices is a promising approach, but its practice varies greatly. This practice has been developing in Western countries and is tending to increase. The implementation of case managers seems to be associated with certain characteristics linked to general practitioner practices (practice location, practice size), whereas it does not seem to depend on the personal characteristics of general practitioners, such as age or sex.

Primary Healthcare Case Management Nurses and Assistance Provided to Chronic Patients: A Narrative Review

Population aging is causing increases in the numbers of chronic diseases, with the consequent need for changes in health systems to better assist patients with chronic conditions. A narrative review was conducted in this study with the objective of analysing the scientific evidence on the care and assistance provided by Case Management Nurses (CMNs) to chronic patients in primary healthcare. A total of 15 articles published in English, Spanish, and Portuguese were selected in the following databases: PubMed, Embase, Cochrane Library, Scopus, Dialnet, Cinahl, and Web of Science. In total, 46.6% of the studies showed the assistance provided by CMNs for chronic pathologies. Most of the articles selected (80%) considered that the assistance offered by case management nurses in relation to chronic diseases is effective, enabling cost reductions, which supposes benefits at the economic and political levels. It was concluded that CMNs have proven to be efficient in caring for people with chronic diseases, improving the quality of life of these people and their caregivers; therefore, they have a fundamental role in the PHC.

Healthcare experiences of people living with medically unexplained symptoms: a systematic review

A diagnosis of medically unexplained symptoms (MUS) is made when a person reports a complaint for which no organic disease can be detected. People with MUS commonly present to primary care services in the UK; however, there is no consensus regarding the evidence base for care. This literature review explores the experiences of these patients when they interact with health services. The following themes emerged: experience of diagnosis; expectations; communication; and healthful relationships. People with MUS report negative experiences of health care. Nurses in primary care have an opportunity to provide person-centred care to support these patients, and research could explore the potential contribution of nurses working in primary care in the UK to support them and enhance the evidence base for practice.

Experiences of Ambulatory Patients With Huntington's Disease With Case Management: A Qualitative Study

PURPOSE/OBJECTIVES

Huntington's disease (HD) requires high-quality care to reduce disruption of the patient system, prevent crisis situations, and prevent early admission in a nursing home. In the Netherlands, case management has been available for the last to 9 years for people with HD. However, there is a notable gap in understanding experiences and beliefs of HD patients regarding case managers' care, guidance, and support for quality of life. To improve the international quality of care for people with HD, insight in experiences of ambulatory HD patients with the care, guidance, and support received from a case manager HD (CMHD) is crucial.

PRIMARY PRACTICE SETTING

Ambulatory care.

FINDINGS/CONCLUSIONS

Ambulatory patients with HD highly appreciate and value the role and support of the CMHD. This was reflected in four themes: (1) the CMHD as a person, with commitment, sympathy, and reliability as central concepts; (2) the CMHD as a professional, with the key roles of coordinator, point of contact, expert, and supporter; (3) impact of the CMHD on quality of life, with support of coping with decline and monitoring the home situation as important subthemes; and (4) support of the CMHD for family members, with providing help and giving attention as subthemes. This insight into patients' experiences of the CMHD's role adds value to the improvement of the international quality of care for people with HD.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Commitment, expertise, support for both family members and patients, and bond of trust from the CMHD are experienced as very valuable. These qualitative findings from a patient's perspective add significantly to the body of knowledge on CMHD's role and practices as "spider at the center of the web."

Identifying complex patients in family medicine for potential benefit from a case manager: a short questionnaire derived from the INTERMED Self-Assessment (IMSA) questionnaire

Purpose

To investigate how useful the Intermed-Self Assessment (IMSA) questionnaire and its components were for identifying which patient candidates would benefit most from case management (CM) in general practice.

Methods

The study was carried out in a group family medicine practice in Lausanne comprising seven GPs and four medical assistants, from February to April 2019. All the patients attending the practice between February and April 2019 were invited to complete the IMSA questionnaire. Additionally, their GPs were asked for their opinions on the potential benefits of each patient being assigned a case manager. Each IMSA item’s value has been assessed as a predictor of GPs’ opinions by using multivariate logistic models. A score including items retained as predictor was built.

Results

Three hundred and thirty one patients participated in the study (participation rate: 62%). Three items from the 20 item IMSA were sufficient to predict GPs’ opinions about whether their patients could be expected to benefit if assigned a case manager. Those items addressed the patient’s existing chronic diseases (item1), quality of life in relation to existing diseases (item 3), and their social situation (item 9). Using these three items as a score, a cut-off at 4 gave a sensitivity of 70% (ability to correctly identify patients who could benefit from a CM) and specificity of 73% (ability to correctly identify patients who should not benefit from a CM) and concerned about one patient in two.

Conclusion

Identifying complex patients suitable for case management remains a challenge for primary care professionals. This paper describes a novel approach using a structured process of combining the results of standardized tools such as the one defined in this study, and the experience of the primary care team.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01876-8.

Improving patient well-being in the United States through care coordination interventions informed by social determinants of health

Health and well-being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification of patients for care coordination is typically based on claim-driven risk assessments. Evidence shows that social determinants of health (SDOH) drive risk for adverse health outcomes but are omitted from existing risk tools. Missed opportunities for care coordination contribute to increased healthcare costs, poorer health outcomes and reduced patient well-being. To address the gap of risk-informed care coordination that includes SDOH, the aim of this project was to implement process improvement of a system's care coordination program through refined patient selection and customised engagement in intensive care coordination. A non-randomised care coordination quality improvement project was conducted at a community health centre in 2020. Inclusion criteria (i.e. presence of risk attribution score, SDOH questionnaire completed) resulted in 540 patients being offered care coordination services; Patients having at least one month of care coordination were included in the analysis (N = 216). Analysis included the 216 patients that chose participation and the 324 patients that maintained usual care. Descriptive statistics were generated to distinguish patient demographics, frequency of care coordination contact, and specific SDOH insecurities for both the study and comparison groups. Paired t-tests were incorporated to evaluate statistical significance of the intervention group. Impact on well-being, SDOH barriers, appointment adherence and health outcomes were assessed in both conditions. Intervention condition patients reported improvement in well-being [feeling anxious (t = 4.051; p < 0.000)] and reduced SDOH barriers [food access (t = 4.662; p < 0.000); housing (t = 2.203; p = 0.008)] that were significantly different from the usual care condition in the expected directions. Care coordination based on factors including SDOH risks shows promise in improving patient well-being. Future research should refine this approach for comprehensive risk assessment to intervene and support patient health and well-being.

The Influence of Contextual Factors on the Process of Formulating Strategies to Improve the Adoption of Care Manager Activities by Primary Care Nurses

Background:

Primary care nurses are well-suited to provide care management for common mental disorders, but their practices depend on context. Various strategies can be considered to improve the adoption of nursing care manager activities, but data from implementation studies rarely address strategy formulation.

Aim:

To analyze the influence of contextual factors on strategy formulation to improve the adoption of care manager activities by primary care nurses.

Method:

A qualitative multiple case study in three primary care clinics was carried out. Data were collected through individual interviews (n = 32) and observations (n = 7), working group meetings, and relevant documents. Thematic analysis was conducted.

Results:

Contextual factors influenced strategy formulation through organizational readiness for change, which resulted from tension for change and perceived organizational ability to implement change. Tension for change was generated through the perceived gap between patient needs and service availability, perceived compatibility with the nurses work environment, and their assessment of their capacity to perform care manager activities or acquire the necessary skills.

Conclusion:

Future studies should give sufficient attention to implementation strategy formulation and consider the dynamic role of organizational readiness for change when facilitating the adoption of evidence-based practices for common mental disorders in primary care.

Nurse managers experiences of their leadership roles in a specific mining primary healthcare service in the West Rand

BACKGROUND

Nurse managers are leaders in mining primary healthcare. Their leadership roles include inspiring and empowering operational managers and nursing personnel, by leading with competence developing them to become followers with insight and direction. However, these leadership roles are not clearly defined, and are negatively influenced by the traditional mining leadership style.

OBJECTIVES

The aim of this study was to explore and describe the nurse managers' experiences of their leadership roles in a specific mining primary healthcare service on the West Rand, to develop recommendations to enhance these roles.

METHOD

A qualitative, exploratory, descriptive and contextual research design was used in this study, following a phenomenological approach as a research method. A non-probability purposive sampling method was used. Nurse managers described experiences of their leadership roles during individual phenomenological interviews. Data saturation was reached on participant number 7. To analyse data, four stages of Giorgi's descriptive phenomenological data analysis was used. An independent coder coded the data and a consensus meeting was held. The study was guided by the theoretical framework of Winkler's role theory.

RESULTS

The following subthemes emanated from data analysis: (1) leadership role ambiguity, (2) leadership roles experienced and (3) challenges experienced in leadership roles.

CONCLUSION

This study revealed that the leadership roles for nurse managers in a specific mining primary healthcare service are not clearly defined. Hence enhancements and expansions of these leadership roles remained stagnant. A clearly defined policy on leadership roles for nurse managers should be developed.

Nurse Case Manager: Measurement of Care Coordination Activities and Quality and Resource Use Outcomes When Caring for the Complex Patient With Hematologic Cancer

BACKGROUND

The lack of coordination of care for complex patients in the hematology setting has prompted nurse case managers (NCMs) to coordinate that care.

OBJECTIVES

This article aimed to identify the frequency of NCM care coordination activities and quality and resource use outcomes in the complex care of patients in the hematology setting.

METHODS

NCM aggregate data from complex outpatients with hematologic cancer were retrieved from electronic health records at a comprehensive cancer center in the midwestern United States. Total volume of activities and outcomes were calculated as frequency and percentage.

FINDINGS

Care coordination activities included communicating; monitoring, following up, and responding to change; and creating a proactive plan of care. Quality outcomes included improving continuity of care and change in health behavior, and resource use outcomes most documented were patient healthcare cost savings.

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

Background

In 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice.

Objectives

To map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions.

Methods

For the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA).

Results

A total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights.

Limitations

The research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.

Conclusions

Overall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services.

Future work

Research should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Case management as a high-risk prenatal care strategy

OBJECTIVE

to discuss the benefits of using high-risk prenatal case management.

METHOD

a qualitative, convergent care study with six high-risk pregnant women, performed in a municipality in the south of Brazil. Data were produced by case management from April to August of 2017 through observation-participant. Analysis followed the processes of Convergent Care Research: apprehension, synthesis, theorization and transfer.

RESULTS

case management identified important elements in the care of pregnant women, which denoted a greater complexity to the cases; was shown as a relevant space for nurses to act, because it is an intervention that requires knowledge and specific skills.

FINAL CONSIDERATIONS

case management provides differentiated management in complex cases, facilitates the flow between health services, concretizing the comprehensiveness and equity of the care. It was found, in the convergence between research and care, that participants were benefited by case management.

Treatment of Depression in Integrated Care: Implementation of the Nurse Care Manager

The collaborative care model is an effective model for improving depression symptoms in patients in a primary care (PC) setting. An essential role in this model is the care manager (CM), and nurses have been effective in this role. However, there remains a question of how to best design, train, and implement this nurse CM role in PC. The purpose of this review is to provide readers with a critical description of what processes for training and implementation of a collaborative nurse CM role have been be successful in the literature, specifically as it pertains to supporting patients with depression and chronic medical illnesses in an integrated PC setting. A literature review of PubMed, CINAHL, PsychINFO, Scopus, and the Cochrane Collaborative was conducted in October 2018. Successful nurse CM interventions have included regular patient follow-up, symptom check-in, treatment monitoring, goal setting, and education. Psychological support techniques such as Problem-Solving Therapy, behavioral activation, and motivational interviewing have been useful in supporting patient care-plan engagement and goal achievement. Nurse CM training should support the successful implementation of the designed role. Nurse CMs have an opportunity to significantly impact depressive outcomes of patients with depression and long-term health conditions. Further research is needed to explore the potential that this nursing role has as well as how to best operationalize this role.