Experiences of case managers in providing person-centered and integrated care based on the Chronic Care Model: A qualitative study on embrace

Partners in vaccination: A community-based intervention to promote COVID-19 vaccination among low-income homebound and disabled adults

BACKGROUND

Care managers (CM) for low-income disabled clients may address COVID-19 vaccine hesitancy with specific training.

OBJECTIVE

To assess the Partners in Vaccination (PIV) that trained CMs of a homecare program for disabled adults to promote COVID-19 vaccination.

METHODS

We randomized 78 CMs to PIV intervention (N = 38) or control (N = 40). PIV featured motivational interviewing (MI) skills and educational materials for unvaccinated clients. The primary outcome was first COVID-19 vaccination between December 1, 2021 and June 30, 2022 for clients of intervention CMs versus control CMs. Mixed method analysis included key informant interviews conducted from 5/24/22 to 7/25/22 with CMs, administrators, and clients about the PIV intervention.

RESULTS

Among 1939 clients of 78 study CMs, 528 (26.8 %) were unvaccinated by December 1, 2021 (274 clients of intervention CMs; 254 clients of control CMs). These clients' mean age was 62.3 years old (SD = 22.4) and 54 % were Black or Hispanic/Latino. First vaccination rate did not differ for intervention and control groups (6.2 % vs. 5.9 %, p = .89) by 6/30/2022. Barriers to addressing COVID-19 vaccination from interviews with 7 CMs and administrators were competing responsibilities and potentially antagonizing clients. Seven interviewed clients (five vaccinated and two unvaccinated) cited concerns about vaccination they heard from their family/friends and belief that risks of COVID-19 infection may be less than vaccination. Yet, some clients were receptive to physician recommendations.

CONCLUSION

Training CMs to promote COVID-19 vaccination for disabled clients did not increase first vaccination rates. CMs preferred their usual role of coordinating care and, even after the training, expressed discomfort with this potentially polarizing topic.

Perceptions and Current Practices in Patient-Centered Care: A Qualitative Study of Ryan White HIV Providers in South Florida

Background: Patient-centered care (PCC) improves HIV adherence and retention, though lack of consensus on its conceptualization and understanding how it is interpreted has hindered implementation. Methods: We recruited 20 HIV providers at Ryan White Programs in FL for in-depth interviews. Thematic analysis identified core consistencies pertaining to: 1) provider perceptions, 2) current practices promoting PCC. Results: Provider perceptions of PCC emerged under four domains: 1) holistic, 2) individualized care, 3) respect for comfort and security, and 4) patient engagement and partnership. PCC practices occurred at multiple levels: 1) individual psychosocial and logistical support, 2) interpersonal support within patient-provider relationships through respectful communication and active engagement, and 3) institutional practices including feedback mechanisms, service integration, patient convenience, and diverse staffing. Conclusions: Our findings highlight the central tenets of PCC as respectful, holistic, individualized, and engaging care. We offer an HIV-adapted framework of PCC as a multilevel construct to guide future intervention.

[Experiences of Transitional Care for Medicaid Case Managers]

PURPOSE

This phenomenological study tried to understand the essence of the transitional care experience of medicaid case managers and its structural meaning. In addition, it was attempted to establish a system of transitional care and seek support measures for medicaid case managers.

METHODS

The participants of this study were 7 medicaid case managers who had spent more than 1 year and 6 months in medicaid pilot project. Data were collected with individual in-depth interviews from June to December 2021. The data were analyzed by Giorgi's phenomenological analysis method.

RESULTS

The seven constituents derived from the results of this study were 'struggle to establish a living environment', 'dedication to supporting independent living', 'anxiety about safety', 'pressure on care responsibilities', 'distress in building the pilot project', 'pride in role', and 'expectation for improvement'.

CONCLUSION

The study results provide a comprehensive understanding of the transition care reality for medicaid case managers. They also shed light on managers' perceptions and attitudes. These findings can serve as fundamental information for establishing support measures for medicaid case managers and transitional care systems.

Healthcare professionals' experiences of job satisfaction when providing person-centred care: a systematic review of qualitative studies

OBJECTIVES

This qualitative systematic review aimed to explore and synthesise healthcare professionals' (HCPs) experiences of job satisfaction when providing person-centred care (PCC) in healthcare settings in Europe.

METHOD

This systematic review of qualitative studies was followed by a thematic synthesis applying an inductive approach. Studies concerning HCPs and different levels of healthcare in Europe were eligible for inclusion. The CINAHL, PubMed and Scopus databases were searched. Study titles, abstracts and full texts were screened for relevance. Included studies were assessed for methodological quality using a quality appraisal checklist. Data were extracted and synthesised via thematic synthesis, generating analytical themes.

RESULTS

Seventeen studies were included in the final thematic synthesis, and eight analytical themes were derived. Most studies were conducted in Sweden and the UK and were performed in hospitals, nursing homes, elderly care and primary care. Thirteen of these studies were qualitative and four used a mixed-method design in which the qualitative part was used for analysis. HCPs experienced challenges adapting to a new remoulded professional role and felt torn and inadequate due to ambiguities between organisational structures, task-oriented care and PCC. Improved job satisfaction was experienced when providing PCC in line with ethical expectations, patients and colleagues expressed appreciation and team collaboration improved, while learning new skills generated motivation.

CONCLUSION

This systematic review found varied experiences among HCPs. Notably, the new professional role was experienced to entail disorientation and uncertainty; importantly, it also entailed experiences of job satisfaction such as meaningfulness, an improved relationship between HCPs and patients, appreciation and collaboration. To facilitate PCC implementation, healthcare organisations should focus on supporting HCPs through collaborational structures, and resources such as time, space and staffing.

PROSPERO REGISTRATION NUMBER

CRD42022304732.

Case management for integrated care of older people with frailty in community settings

BACKGROUND

Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems.

OBJECTIVES

To assess the effects of case management for integrated care of older people living with frailty compared with usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care.

AUTHORS' CONCLUSIONS

We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.

Experiences of older people, healthcare providers and caregivers on implementing person-centered care for community-dwelling older people: a systematic review and qualitative meta-synthesis

BACKGROUND

Person-centered care (PCC) is a critical approach to improving the quality of care for community-dwelling older people. Old-age care services could be provided according to older peoples' choices, needs, and preferences. The purpose of this study was to synthesize research evidence on the experiences of older people, healthcare providers, and caregivers with PCC and to identify the enablers and barriers to implementing PCC for community-dwelling older people.

METHODS

A meta-synthesis of qualitative research design was adopted. Data searches were performed using CINAHL (EBSCOhost), PubMed (OvidSP), Embase (Ovid), Cochrane Database, and PsycINFO (Ovid) in published articles and were reviewed from the earliest date to February 2023. The Qualitative Method Appraisal Tool was used to conduct a quality appraisal on selected articles. Data were extracted based on the capacity, opportunity, and motivation-behavior model (COM-B model), and the findings were synthesized using the meta-aggregative approach.

RESULTS

Twelve included articles were analyzed to identify 122 findings that were organized into 11 categories and combined into three synthesized findings-capacities of older people, healthcare providers, and caregivers; opportunities in the implementation of PCC; motivation in implementing PCC. Capacities consisted of a lack of person-centered knowledge and skills, negative attitudes toward shared decision-making, and a lack of formal training to enhance capabilities among HCPs. Opportunities included a lack of coordination in resource allocation, strengthening multidisciplinary teamwork, establishing a desirable environment, and time constraints. Motivation in implementing PCC included encouraging self-reflection and regulation, respecting the autonomy of older people, lack of clear reward and empowerment mechanisms, and being resilient and optimistic.

CONCLUSIONS

The findings of this research provide a reference for implementing successful PCC in the community. The researchers identified barriers and facilitators of implementing PCC, facilitating through stakeholder's person-centered knowledge and skills being valued and respecting the autonomy of older people. Establishing a positive environment and strengthening multidisciplinary team members also promotes the implementation of PCC. However, additional studies are required to explore the influencing factors and address the barriers.

Implementation of nursing case management to improve community access to care: A scoping review

Background

Case management is an approach used to help patients locate and manage health resources as well as to enhance effective communication among patients, families, and health systems. Nurses' role as case managers has been proven effective in reducing healthcare costs among patients with chronic diseases. However, little is known about its implementation in improving access to care in community-based settings.

Objectives

This scoping review aimed to examine the components of nursing case management in improving access to care within community settings and to identify the issues of community-based nursing case management for future implications.

Design

This study was conducted following the framework of scoping review.

Data Sources

The authors systematically searched five electronic databases (CINAHL, PubMed, Science Direct, Scopus, and Google Scholar) for relevant studies published from January 2010 to February 2021. Only original studies involving nurses as one of the professions performing case management roles in the community-based settings, providing 'access to care' as the findings, were included.

Review Methods

The article screening was guided by a PRISMA flowchart. Extraction was performed on Google Sheet, and synthesis was conducted from the extraction result.

Results

A total of 19 studies were included. Five components of nursing case management to improve access to care were identified: 1) Bridging health systems into the community, 2) Providing the process of care, 3) Delivering individually-tailored health promotion and prevention, 4) Providing assistance in decision making, and 5) Providing holistic support. In addition, three issues of nursing case management were also identified: 1) Regulation ambiguity, 2) High caseloads, and 3) Lack of continuing case management training.

Conclusion

Care coordination and care planning were the most frequent components of nursing case management associated with access to care. These findings are substantial to improve nurses' ability in performing the nursing process as well as to intensify nurses' advocacy competence for future implications.

Easier Said Than Done: Healthcare Professionals' Barriers to the Provision of Patient-Centered Primary Care to Patients with Multimorbidity

Patient-centered care (PCC) has the potential to entail tailored primary care delivery according to the needs of patients with multimorbidity (two or more co-existing chronic conditions). To make primary care for these patients more patient centered, insight on healthcare professionals’ perceived PCC implementation barriers is needed. In this study, healthcare professionals’ perceived barriers to primary PCC delivery to patients with multimorbidity were investigated using a constructivist qualitative design based on semi-structured interviews with nine general and nurse practitioners from seven general practices in the Netherlands. Purposive sampling was used, and the interview content was analyzed to generate themes representing experienced barriers. Barriers were identified in all eight PCC dimensions (patient preferences, information and education, access to care, physical comfort, emotional support, family and friends, continuity and transition, and coordination of care). They include difficulties achieving mutual understanding between patients and healthcare professionals, professionals’ lack of training and education in new skills, data protection laws that impede adequate documentation and information sharing, time pressure, and conflicting financial incentives. These barriers pose true challenges to effective, sustainable PCC implementation at the patient, organizational, and national levels. Further improvement of primary care delivery to patients with multimorbidity is needed to overcome these barriers.

Results of Nurse Case Management in Primary Heath Care: Bibliographic Review

BACKGROUND

The new characteristics of today's population, together with the presence of chronic diseases in the elderly, require a new approach to care, promoting coordination between different levels of care. In this sense, we find the figure of the nurse case manager (NCM) in primary health care mainly responsible for ensuring continuity of care in complex patients with chronic diseases.

OBJECTIVE

to describe the role of the NCM in care management, determining its effectiveness in addressing chronic disease (health outcomes and quality of life) and its efficiency in the health system.

METHODS

Bibliographic review of scientific evidence on case management applied to nursing. Between March and April 2020 a bibliographic search was carried out in the Dialnet, Scielo, Scopus and Pubmed databases.

INCLUSION CRITERIA

articles written in the last 5 years, which analyze how this nursing rol influences the care and health of patients.

RESULTS

A total of 16 articles were selected. The NCM reduced the use of the emergency department, hospital admissions, readmissions, and the duration of these in the patients studied.

CONCLUSION

The NCM is effective and efficient for both patients and health institutions, and a common practice model is needed that includes standardized protocols and evidence-based practices.

Integrated Care for Older Adults: A Struggle for Sustained Implementation in Northern Netherlands

Introduction:

Integrated care has been suggested as a promising solution to the disparities in access and sustained high quality long-term care emerging in Europe’s ageing population. We aim to gain a better understanding of context-specific barriers to and facilitators of implementation of integrated care by doing a retrospective assessment of seven years of Embrace. This Dutch integrated person-centred health service for older adults was based on two evidence-based models (the Chronic Care Model and the Kaiser Permanente Triangle). Despite successful deployment the programme ended in 2018. In this case study we assess the impact of the programme based on past evaluations, reflect on why it ended, lessons learned and ideas to take forward.

Discussion:

The majority of health outcomes were positive and the perceived quality of care improved, albeit no clear-cut savings were observed, and the costs were not balanced across stakeholders. The Embrace payment model did not support the integration of health services, despite reforms in long-term care in 2015.

Key lessons:

Enabling policy and funding are crucial to the sustained implementation of integrated person-centred health services. The payment model should incentivize the integration of care before the necessary changes can be made at organizational and clinical levels towards providing proactive and preventive health services.

Effectiveness of the integrated care model Salut+Social in patients with chronic conditions: A mixed methods study protocol

INTRODUCTION

Integrated care models aim to provide solutions to fragmentation of care by improving coordination. This study will evaluate the effectiveness of a new integrated care model (Salut + Social), which will promote the coordination and communication between social and healthcare services in southern Catalonia (Spain) to improve quality of life, adherence to treatment and access to medical services for patients with chronic conditions, and also to reduce caregiver burden. Additionally, we will evaluate the experience of caregivers, health professionals and social workers with the new model implemented.

METHODS AND ANALYSIS

A clinical trial using mixed methodology will be carried out. The intervention consists of improving the coordination between the social and healthcare sectors during a 6-month period, by means of information and communication technology (ICT) tools that operate as an interface for the integrated care model. The study subjects are primary care patients with chronic health and social conditions that can benefit from a collaborative and coordinated approach. A sample size of 141 patients was estimated. Questionnaires that assess quality of life, treatment adherence, medical service and caregiver burden will be used at baseline and at 6, 9, and 12 months after the beginning of the study. The principal variable is quality of life. For statistical analysis, comparisons of means and proportions at different time points will be performed. A discussion group and semi-structured interviews will be conducted with the aim of improving the care model taking into account the opinions of professionals and caregivers. A thematic content analysis will be carried out.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Clinical Research Ethics Committee of the Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (code P17/100). Articles will be published in international, peer-reviewed scientific journals.

TRIAL REGISTRATION

Clinical-Trials.gov: NCT04164160.

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.

Goal planning in person-centred care supports older adults receiving case management to attain their health-related goals

PURPOSE

Care for older adults should preferably be provided in a person-centred way that includes goal planning. The aim of the present cohort study is to gain an insight into the results of goal planning, in a person-centred care setting for community-living older adults.

MATERIALS AND METHODS

Within Embrace, a person-centred and integrated care service, older adults set goals with the aim to improve health-related problems. For every goal, they rated severity scores ranging from 0 (no problem) to 10 (extremely severe): a baseline score, a target score and, within one year, an end score to evaluate these goals. The differences between baseline and end scores (goal progress) and target and end scores (goal attainment), and the percentage of goals attained were calculated and compared between health-related domains (i.e., mental health, physical health, mobility, and support).

RESULTS

Among 233 older adults, 836 goal plans were formulated of which 74% (95% Confidence Interval: 71-77) were attained. Goals related to physical health were the most likely to be attained and goals for mobility and pain the least likely.

CONCLUSIONS

Older adults are able to attain health-related goals through collaborative goal planning. We recommend future integrated care programmes for older adults to incorporate goal-planning methods to achieve person-centred care.IMPLICATIONS FOR REHABILITATIONOlder adults experiencing frailty or complex care needs and receiving individual support within an integrated care setting are able to formulate and attain goals using goal planning with severity scores.Goal plans of community-living older adults mostly aim at improving health-related problems concerning physical health, mobility, or support.Goals related to physical health are the most likely to be attained, while goals for mobility and pain are the least likely to be attained.

[Towards excellence in hospital management. A description of strategical management model]

BACKGROUND AND OBJECTIVE

Health services are evolving from the traditional view of paternalistic medicine towards a more informed and participatory patient-provider relationship. This situation includes the empowerment and participation of patients and their families in health management, including their joint responsibility in the development of health services. The objective of this article is to describe the experience in a large teaching hospital in Spain on the application of a model that focuses on a three-fold approach to healthcare management that includes the experience of the patient.

MATERIAL AND METHODS

This approach is identified by the initials EMC2 transforming the E of excellence into 3main areas of improvement: methodology, clinical knowledge and client, or patient, experience. the model has been implemented in different areas: childbirth, asthma care, outpatient clinics, and operating theatre.

RESULTS

In the case of childbirth, there was a reduction in caesarean sections, episiotomies, induction of delivery, mean hospital stay, and number of deliveries with instrumentation. The Net Promoter Score went from 82 to 86. There was also an improvement in the areas of patient experience, hospital procedures, and clinical knowledge. Qualitative improvement results were obtained in other areas such as, asthma management, outpatient visits, and the operating room.

CONCLUSIONS

This model can be applied to different areas. It promotes patient-focused practice, as well as system sustainability, efficiency, effectiveness, and level of satisfaction with the health care process.