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Teper MH, Vedel I, Yang XQ, Margo-Dermer E, Hudon C. Understanding Barriers to and Facilitators of Case Management in Primary Care: A Systematic Review and Thematic Synthesis. Ann Fam Med 2020; 18:355-363. [PMID: 32661038 PMCID: PMC7358023 DOI: 10.1370/afm.2555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 10/30/2019] [Accepted: 11/29/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Despite evidence on the benefits of case management for the care of patients with complex needs in primary care, implementing the program-necessary to achieve its benefits-has been challenging worldwide. Evidence on factors affecting implementation remains disparate. Accordingly, the objective of this systematic review was to identify barriers to and facilitators of case management, from the perspectives of health care professionals, in primary care settings around the world. METHODS We conducted a systematic review and thematic synthesis of qualitative findings. In collaboration with 2 librarians, we searched 3 electronic databases (MEDLINE, CINAHL, EMBASE) for studies related to factors affecting case management function in primary care. Two researchers screened titles, abstracts, and full texts for inclusion, then assessed included studies for quality. Results from included studies were synthesized by thematic synthesis, and a framework was developed. RESULTS Of 1,640 unique records identified, 22 studies, originating from 6 countries, met the inclusion criteria. We identified 9 barriers and facilitators: family context; policy and available resources; physician buy-in and understanding of the case manager role; relationship building; team communication practices; autonomy of case managers; training in technology; relationships with patients; and time pressure and workload. We describe these factors, then present a framework demonstrating the relationships among them. CONCLUSIONS Our study's findings show that multiple factors influence case management implementation. These findings have implications for researchers, clinicians, and policy makers who strive to implement or reform case management programs in local or larger primary care settings.
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Affiliation(s)
- Matthew Hacker Teper
- Department of Family Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Isabelle Vedel
- Department of Family Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Xin Qiang Yang
- Department of Family Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Eva Margo-Dermer
- Department of Family Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine, Univer-sité de Sherbrooke, Sherbrooke, Québec, Canada
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Sheaff R, Halliday J, Øvretveit J, Byng R, Exworthy M, Peckham S, Asthana S. Integration and continuity of primary care: polyclinics and alternatives – a patient-centred analysis of how organisation constrains care co-ordination. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03350] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAn ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level.ObjectivesTo examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care.MethodsMultiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care.ResultsStarting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance.ConclusionsOn balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Rod Sheaff
- School of Government, Plymouth University, Plymouth, UK
| | | | - John Øvretveit
- Medical Management Centre, Karolinska Institutet Stockholm, Stockholm, Sweden
| | - Richard Byng
- Health Services Management Centre, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mark Exworthy
- Centre for Health Services Studies, University of Birmingham, Birmingham, UK
| | - Stephen Peckham
- Department of Health Services Research and Policy, University of Kent, Kent, UK
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Gage H, Grainger L, Ting S, Williams P, Chorley C, Carey G, Borg N, Bryan K, Castleton B, Trend P, Kaye J, Jordan J, Wade D. Specialist rehabilitation for people with Parkinson’s disease in the community: a randomised controlled trial. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02510] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundMultidisciplinary rehabilitation is recommended for Parkinson’s disease, but evidence suggests that benefit is not sustained.Objectives(1) Implement a specialist domiciliary rehabilitation service for people with Parkinson’s and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners.DesignPragmatic three-parallel group randomised controlled trial.SettingCommunity, county of Surrey, England, 2010–11.ParticipantsPeople with Parkinson’s, at all stages of the disease, and live-in carers.InterventionsGroups A and B received specialist rehabilitation from a multidisciplinary team (MDT) – comprising Parkinson’s nurse specialists, physiotherapists, occupational therapists, and speech and language therapists – delivered at home, tailored to individual needs, over 6 weeks (about 9 hours’ individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson’s (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support).Main outcome measuresFollow-up assessments were conducted in participants’ homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson’s Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning.ResultsA total of 306 people with Parkinson’s (and 182 live-in carers) were randomised [group A,n = 102 (n = 61); group B,n = 101 (n = 60); group C,n = 103 (n = 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson’s,n = 227 (live-in carers,n = 125)] [group A,n = 75 (n = 45); group B,n = 69 (n = 37); group C,n = 83 (n = 43)] showed that, at the end of the MDT intervention, people with Parkinson’s in groups A and B, compared with group C, had reduced anxiety (p = 0.02); their carers had improved psychological well-being (p = 0.02). People with Parkinson’s in groups A and B also had marginally reduced disability (primary outcome,p = 0.09), and improved non-motor symptoms (p = 0.06) and health-related quality of life (p = 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (p = 0.001); non-motor symptoms (p = 0.05); health-related quality of life (p = 0.07); and self-efficacy (p = 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (p = 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson’s, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds).ConclusionsFurther research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.Study registrationCurrent Controlled Trials: ISRCTN44577970.FundingThis project was funded by the National Institute for Health Research Health Services and Delivery Research programme and the South East Coast Dementias and Neurodegenerative Disease Research Network (DeNDRoN), and the NHS South East Coast. The report will be published in full inHealth Services and Delivery Research; Vol. 2, No. 51. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Heather Gage
- School of Economics, University of Surrey, Guildford, UK
| | - Linda Grainger
- School of Economics, University of Surrey, Guildford, UK
| | - Sharlene Ting
- School of Economics, University of Surrey, Guildford, UK
| | - Peter Williams
- Department of Mathematics, University of Surrey, Guildford, UK
| | | | - Gillian Carey
- School of Economics, University of Surrey, Guildford, UK
| | - Neville Borg
- School of Economics, University of Surrey, Guildford, UK
| | - Karen Bryan
- Division of Health and Social Care, University of Surrey, Guildford, UK
| | | | - Patrick Trend
- Department of Neurology, Royal Surrey County Hospital, Guildford, UK
| | - Julie Kaye
- Division of Health and Social Care, University of Surrey, Guildford, UK
| | - Jake Jordan
- School of Economics, University of Surrey, Guildford, UK
| | - Derick Wade
- Oxford Centre for Enablement, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
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Gage H, Ting S, Williams P, Bryan K, Kaye J, Castleton B, Trend P, Wade D. A comparison of specialist rehabilitation and care assistant support with specialist rehabilitation alone and usual care for people with Parkinson's living in the community: study protocol for a randomised controlled trial. Trials 2011; 12:250. [PMID: 22112960 PMCID: PMC3261836 DOI: 10.1186/1745-6215-12-250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 11/23/2011] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Parkinson's Disease is a degenerative neurological condition that causes movement problems and other distressing symptoms. People with Parkinson's disease gradually lose their independence and strain is placed on family members. A multidisciplinary approach to rehabilitation for people with Parkinson's is recommended but has not been widely researched. Studies are needed that investigate cost-effective community-based service delivery models to reduce disability and dependency and admission to long term care, and improve quality of life. METHODS A pragmatic three parallel group randomised controlled trial involving people with Parkinson's Disease and live-in carers (family friends or paid carers), and comparing: management by a specialist multidisciplinary team for six weeks, according to a care plan agreed between the professionals and the patient and carer (Group A); multidisciplinary team management and additional support for four months from a trained care assistant (Group B); usual care, no coordinated team care planning or ongoing support (Group C). Follow up will be for six months to determine the impact and relative cost-effectiveness of the two interventions, compared to usual care. The primary outcomes are disability (patients) and strain (carers). Secondary outcomes include patient mobility, falls, speech, pain, self efficacy, health and social care use; carer general health; patient and carer social functioning, psychological wellbeing, health related quality of life. Semi structured interviews will be undertaken with providers (team members, care assistants), service commissioners, and patients and carers in groups A and B, to gain feedback about the acceptability of the interventions. A cost - effectiveness evaluation is embedded in the trial. DISCUSSION The trial investigates components of recent national policy recommendations for people with long term conditions, and Parkinson's Disease in particular, and will provide guidance to inform local service planning and commissioning. TRIAL REGISTRATION ISRCTN: ISRCTN44577970.
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Affiliation(s)
- Heather Gage
- Dept of Economics, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - Sharlene Ting
- Dept of Economics, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - Peter Williams
- Dept of Mathematics, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - Karen Bryan
- Division of Health and Social Care, University of Surrey, Guildford, Surrey GU2 7TE, UK
| | - Julie Kaye
- NHS Surrey, Cedar Court, Guildford Road, Leatherhead, Surrey, KT22 9AE, UK
| | - Beverly Castleton
- Movement Disorders Service, Ashford St Peter's Hospital, Guildford Road, Chertsey, Surrey, KT16 9BN, UK
| | - Patrick Trend
- Department of Neurology, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK
| | - Derick Wade
- Oxford Centre for Enablement, Windmill Road, Oxford, Oxfordshire, OX3 7LD, UK
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Do 'virtual wards' reduce rates of unplanned hospital admissions, and at what cost? A research protocol using propensity matched controls. Int J Integr Care 2011; 11:e079. [PMID: 21949489 PMCID: PMC3178802 DOI: 10.5334/ijic.654] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This retrospective study will assess the extent to which multidisciplinary case management in the form of virtual wards (VWs) leads to changes in the use of health care and social care by patients at high risk of future unplanned hospital admission. VWs use the staffing, systems and daily routines of a hospital ward to deliver coordinated care to patients in their own homes. Admission to a VW is offered to patients identified by a predictive risk model as being at high risk of unplanned hospital admission in the coming 12 months. STUDY DESIGN AND DATA COLLECTION METHODS We will compare the health care and social care use of VW patients to that of matched controls. Controls will be drawn from (a) national, and (b) local, individual-level pseudonymous routine data. The costs of setting up and running a VW will be determined from the perspectives of both health and social care organizations using a combination of administrative data, interviews and diaries. METHODS OF ANALYSIS Using propensity score matching and prognostic matching, we will create matched comparator groups to estimate the effect size of virtual wards in reducing unplanned hospital admissions. CONCLUSIONS THIS STUDY WILL ALLOW US TO DETERMINE RELATIVE TO MATCHED COMPARATOR GROUPS: whether VWs reduce the use of emergency hospital care; the impact, if any, of VWs on the uptake of primary care, community health services and council-funded social care; and the potential costs and savings of VWs from the perspectives of the national health service (NHS) and local authorities.
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McEvoy P, Escott D, Bee P. Case management for high-intensity service users: towards a relational approach to care co-ordination. HEALTH & SOCIAL CARE IN THE COMMUNITY 2011; 19:60-69. [PMID: 21143543 DOI: 10.1111/j.1365-2524.2010.00949.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This study is based on a formative evaluation of a case management service for high-intensity service users in Northern England. The evaluation had three main purposes: (i) to assess the quality of the organisational infrastructure; (ii) to obtain a better understanding of the key influences that played a role in shaping the development of the service; and (iii) to identify potential changes in practice that may help to improve the quality of service provision. The evaluation was informed by Gittell's relational co-ordination theory, which focuses upon cross-boundary working practices that facilitate task integration. The Assessment of Chronic Illness Care Survey was used to assess the organisational infrastructure and qualitative interviews with front line staff were conducted to explore the key influences that shaped the development of the service. A high level of strategic commitment and political support for integrated working was identified. However, the quality of care co-ordination was variable. The most prominent operational factor that appeared to influence the scope and quality of care co-ordination was the pattern of interaction between the case managers and their co-workers. The co-ordination of patient care was much more effective in integrated co-ordination networks. Key features included clearly defined, task focussed, relational workspaces with interactive forums where case managers could engage with co-workers in discussions about the management of interdependent care activities. In dispersed co-ordination networks with fewer relational workspaces, the case managers struggled to work as effectively. The evaluation concluded that the creation of flexible and efficient task focused relational workspaces that are systemically managed and adequately resourced could help to improve the quality of care co-ordination, particularly in dispersed networks.
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Affiliation(s)
- Phil McEvoy
- Salford Community Health, NHS Salford, Salford, UK.
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