Case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs: an implementation and realist evaluation protocol

Patient engagement in health implementation research: A logic model

INTRODUCTION

Growing evidence supports patient engagement (PE) in health implementation research to improve the quality, relevance and uptake of research. However, more guidance is needed to plan and operationalize PE before and throughout the research process. The aim of the study was to develop a logic model illustrating the causal links between context, resources, activities, outcomes and impact of PE in an implementation research programme.

METHODS

The Patient Engagement in Health Implementation Research Logic Model (hereafter the Logic Model) was developed using a descriptive qualitative design with a participatory approach, in the context of the PriCARE programme. This programme aims to implement and evaluate case management for individuals who frequently use healthcare services in primary care clinics across five Canadian provinces. Participant observation of team meetings was performed by all team members involved in the programme and in-depth interviews were conducted by two external research assistants with team members (n = 22). A deductive thematic analysis using components of logic models as coding categories was conducted. Data were pooled in the first version of the Logic Model, which was refined in research team meetings with patient partners. The final version was validated by all team members.

RESULTS

The Logic Model highlights the importance of integrating PE into the project before its commencement, with appropriate support in terms of funding and time allocation. The governance structure and leadership of both principal investigators and patient partners have significant effects on PE activities and outcomes. As an empirical and standardized illustration that facilitates a shared understanding, the Logic Model provides guidance for maximizing the impact of patient partnership in various contexts for research, patients, providers and health care.

CONCLUSION

The Logic Model will help academic researchers, decision makers and patient partners plan, operationalize, and assess PE in implementation research for optimal outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patient partners from the PriCARE research programme contributed to developing the research objectives and designing, developing and validating data collection tools, producing data, developing and validating the Logic Model and reviewing the manuscript.

Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada

BACKGROUND

Case management is one of the most frequently performed interventions to mitigate the negative effects of high healthcare use on patients, primary care providers and the healthcare system. Reviews have addressed factors influencing case management interventions (CMI) implementation and reported common themes related to the case manager role and activities, collaboration with other primary care providers, CMI training and relationships with the patients. However, the heterogeneity of the settings in which CMI have been implemented may impair the transferability of the findings. Moreover, the underlying factors influencing the first steps of CMI implementation need to be further assessed. This study aimed to evaluate facilitators and barriers of the first implementation steps of a CMI by primary care nurses for people with complex care needs who frequently use healthcare services.

METHODS

A qualitative multiple case study was conducted including six primary care clinics across four provinces in Canada. In-depth interviews and focus groups with nurse case managers, health services managers, and other primary care providers were conducted. Field notes also formed part of the data. A mixed thematic analysis, deductive and inductive, was carried out.

RESULTS

Leadership of the primary care providers and managers facilitated the first steps of the of CMI implementation, as did the experience and skills of the nurse case managers and capacity development within the teams. The time required to establish CMI was a barrier at the beginning of the CMI implementation. Most nurse case managers expressed apprehension about developing an "individualized services plan" with multiple health professionals and the patient. Clinic team meetings and a nurse case managers community of practice created opportunities to address primary care providers' concerns. Participants generally perceived the CMI as a comprehensive, adaptable, and organized approach to care, providing more resources and support for patients and better coordination in primary care.

CONCLUSION

Results of this study will be useful for decision makers, care providers, patients and researchers who are considering the implementation of CMI in primary care. Providing knowledge about first steps of CMI implementation will also help inform policies and best practices.

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.

Patient and researcher experiences of patient engagement in primary care health care research: a participatory qualitative study

Background

Studies have highlighted common challenges and barriers to patient engagement in research, but most were based on patient partners' or academic researchers' experiences. A better understanding of how both groups differentially experience their partnership could help identify strategies to improve collaboration in patient engagement research.

Aim

This study aimed to describe and compare patient partners' and academic researchers' experiences in patient engagement research.

Methods

Based on a participatory approach, a descriptive qualitative study was conducted with patient partners and academic researchers who are involved in the PriCARE research programme in primary health care to examine their experience of patient engagement. Individual semi‐structured interviews with patient partners (n = 7) and academic researchers (n = 15) were conducted. Academic researchers' interview verbatims, deidentified patient partners' summaries of their interviews and summaries of meetings with patient partners were analysed using inductive thematic analysis in collaboration with patient partners.

Results

Patient partners and academic researchers' experiences with patient engagement are captured within four themes: (1) evolving relationships; (2) creating an environment that fosters patient engagement; (3) striking a balance; and (4) impact and value of patient engagement. Evolving relationships refers to how partnerships grew and improved over time with an acceptance of tensions and willingness to move beyond them, two‐way communication and leadership of key team members. Creating an environment that fosters patient engagement requires appropriate structural support, such as clear descriptions of patient partner roles; adequate training for all team members; institutional guidance on patient engagement; regular and appropriate translation services; and financial assistance. For patient partners and academic researchers, striking a balance referred to the challenge of reconciling patient partners' interests and established research practices. Finally, both groups recognized the value and positive impact of patient engagement in the programme in terms of improving the relevance of research and the applicability of results. While patient partners and academic researchers identified similar challenges and strategies, their experiences of patient engagement differed according to their own backgrounds, motives and expectations.

Conclusion

Both patient partners and academic researchers highlighted the importance of finding a balance between providing structure or guidelines for patient engagement, while allowing for flexibility along the way.

Patient or Public Contribution

Patient partners from the PriCARE research programme were involved in the following aspects of the current study: (1) development of the research objectives; (2) planning of the research design; (3) development and validation of data collection tools (i.e., interview guides); (4) production of data (i.e., acted as interviewees); (5) validation of data analysis tools (code book); (6) analysis of qualitative data; and (7) drafting of the manuscript and contributing to other knowledge translation activities, such as conference presentations and the creation of a short animated video.

Chatbot-Assisted Care Management

PURPOSE/OBJECTIVES

Chatbots are automated conversation pathways that users can access through text message or email on smartphones or other connected devices. In care management, they can be used to monitor patients' health conditions or recovery from procedures. This article describes nurse care managers' experiences using chatbots in patient care, illustrated through two patient case reviews. Considerations for planning and implementing chatbot technology in care management settings are discussed.

PRIMARY PRACTICE SETTING

This care management service is part of an accountable care organization that serves 582,000 patients in University Hospitals of Cleveland, Ohio. Care management focuses on patients with chronic conditions, recent hospital discharges, and other needs. Care managers comprise a centralized team as well as embedded staff in select primary care practices.

FINDINGS/CONCLUSIONS

The two patient cases are exemplars from the care management program serving patients recently discharged from the hospital with ongoing chronic conditions that increase risk for readmission. Use of chatbots helped overcome obstacles to conventional care management outreach and resulted in improved outcomes and strong trusting relationships with the care managers.

IMPLICATIONS FOR CARE MANAGEMENT PRACTICE

Patients who typically do not respond to other types of care manager outreach may respond to text message-based, asynchronous chatbot communication. Interpersonal relationships between care managers and patients can be strengthened by chatbot support. Chatbot technology tracks patients' progress and offers insights to patients and clinicians to facilitate earlier interventions when problems occur. Chatbots make frequent patient contact to collect and provide routine information, allowing care managers to spend more time on high-value interactions that require clinical judgment. Potential concerns about chatbots include effect on labor force, information security, health equity, and oversight of content.

Case Study With a Participatory Approach: Rethinking Pragmatics of Stakeholder Engagement for Implementation Research

The case study design is particularly useful for implementation analysis of complex health care innovations in primary care that can be influenced by the context of dynamic environments. Case studies may be combined with participatory approaches where academics conduct joint research with nonacademic stakeholders, to foster translation of findings results into practice. The aim of this article is to clarify epistemological and methodological considerations of case studies with a participatory approach. It also aims to propose best practice recommendations when using this case study approach. We distinguish between the participatory case study with full co-construction and co-governance, and the case study with a participatory approach whereby stakeholders are consulted in certain phases of the research. We then compare the epistemological posture of 3 prominent case study methodologists, Yin, Stake, and Merriam, to present the epistemological posture of case studies with a participatory approach. The relevance, applications, and procedures of a case study with a participatory approach methodology are illustrated through a concrete example of a primary care research program (PriCARE). We propose 12 steps for designing and conducting a case study with a participatory approach that may help guide researchers in the implementation analysis of complex health care innovations in primary care.

Reconciling validity and challenges of patient comfort and understanding: Guidelines to patient-oriented questionnaires

Background

Patient‐reported outcome measures (PROMs) are widely recognized as important tools for achieving a patient‐centred approach in health research. While PROMs are subject to several stages of validation during development, even questionnaires with robust psychometric properties may challenge patient comfort and understanding.

Aim

Building on the experience of patient engagement in the PriCARE research programme, this paper outlines the team's response to concerns raised by patient partners regarding the administration of the questionnaire.

Methods

Based on a participatory action research design and the patient engagement framework in the Strategy for Patient‐Oriented Research of the Canadian Institutes of Health Research, PriCARE team members worked together to discuss concerns, review the questionnaires and come up with solutions. Data were collected through participant observation of team meetings.

Results

This paper demonstrates how patient partners were engaged in PriCARE and integrated into the programme's governance structure, focusing on the challenges that they raised regarding the questionnaires and how these were addressed by PriCARE team members in a six‐step approach: (1) Recognizing patient partner concerns, discussing concerns and reframing the challenges; (2) Detailing and sharing evidence of the validity of the questionnaires; (3) Evaluating potential solutions; (4) Searching the literature for guidelines; (5) Creating guidelines; and (6) Sharing and refining guidelines.

Conclusion

This six‐step approach demonstrates how research teams can integrate patient partners as equal members, develop meaningful collaboration through recognition of individual experiences and expertise and ensure that the patient perspective is taken into consideration in research and healthcare innovation.

Patient or Public Contribution

All patient partners from the PriCARE programme were actively involved in the six‐step approach. They were also involved in the preparation of the manuscript.

Protocol for an implementation and realist evaluation of a new organisational model for primary care practices in the canton of Vaud, Switzerland

INTRODUCTION

Continuity of care, especially for patients with complex needs, is a major challenge for healthcare systems in many high-income countries, including Switzerland. Since 2015, a collaborative project between Unisanté-Department of Family Medicine (DMF), some general practitioners (GPs) and canton of Vaud's public health authorities has sought to develop a new organisational model for the provision of primary care to ensure better care coordination and to provide adapted care deliveries to patients' healthcare needs. The model's main component is the addition of a primary care nurse to GPs practices. Three additional tools are individualised patient care plans, electronic medical records and patient empanelment. To assess this model, a 2-year pilot study has begun in nine GPs' practices in the canton. This paper presents the protocol for an evaluation of the implementation and effectiveness of the new organisational model.

METHOD AND ANALYSIS

We will conduct a before-and-after study using a mixed-methods and a realist approach. First, we will use quantitative and qualitative data to assess the new organisational model's implementation (feasibility, fidelity, acceptability and costs) and effectiveness (healthcare services use, patient experience, staff experience and patient-level costs). Combining this data with focus group data will enable a realist evaluation of the pilot project, which will help understand the elements of context and mechanism that affect implementation.

ETHICS AND DISSEMINATION

The evaluation will inform the canton of Vaud's health authorities about the limits of and perspectives for this organisational model. All results will also be made available to the practices and the patients involved. At the end of the project, we will propose organisational adaptations and a sustainable financial model for extending the model to other practices in the canton and potentially to the national level.The canton of Vaud's Human Research Ethics Committee approved the study, and Data Protection and Information Law Authority gave a favourable opinion concerning data processing procedures.

Protocol for a mixed-method analysis of implementation of case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs

INTRODUCTION

Case management (CM) in a primary care setting is a promising approach to integrating and improving healthcare services and outcomes for patients with chronic conditions and complex care needs who frequently use healthcare services. Despite evidence supporting CM and interest in implementing it in Canada, little is known about how to do this. This research aims to identify the barriers and facilitators to the implementation of a CM intervention in different primary care contexts (objective 1) and to explain the influence of the clinical context on the degree of implementation (objective 2) and on the outcomes of the intervention (objective 3).

METHODS AND ANALYSIS

A multiple-case embedded mixed-methods study will be conducted on CM implemented in ten primary care clinics across five Canadian provinces. Each clinic will represent a subunit of analysis, detailed through a case history. Cases will be compared and contrasted using multiple analytical approaches. Qualitative data (objectives 1 and 2) from individual semistructured interviews (n=130), focus group discussions (n=20) and participant observation of each clinic (36 hours) will be compared and integrated with quantitative (objective 3) clinical data on services use (n=300) and patient questionnaires (n=300). An evaluation of intervention fidelity will be integrated into the data analysis.

ETHICS AND DISSEMINATION

This project received approval from the CIUSSS de l'Estrie - CHUS Research Ethic Board (project number MP-31-2019-2830). Results will provide the opportunity to refine the CM intervention and to facilitate effective evaluation, replication and scale-up. This research provides knowledge on how to resp ond to the needs of individuals with chronic conditions and complex care needs in a cost-effective way that improves patient-reported outcomes and healthcare use, while ensuring care team well-being. Dissemination of results is planned and executed based on the needs of various stakeholders involved in the research.

Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis

PURPOSE

Case management (CM) is a promising intervention for frequent users of health care services. Our research question was how and under what circumstances does CM in primary care work to improve outcomes among frequent users with chronic conditions?

METHODS

We conducted a realist synthesis, searching MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) for articles meeting the following criteria: (1) population: adult frequent users with chronic disease, (2) intervention: CM in a primary care setting with a postintervention evaluation, and (3) primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Academic and gray literature were evaluated for relevance and robustness. Independent reviewers extracted data to identify context, mechanism, and outcome (CMO) configurations. Analysis of CMO configurations allowed for the modification of an initial program theory toward a refined program theory.

RESULTS

Of the 9,295 records retrieved, 21 peer-reviewed articles and an additional 89 documents were retained. We evaluated 19 CM interventions and identified 11 CMO configurations. The development of a trusting relationship fostering patient and clinician engagement in the CM intervention was recurrent in many CMO configurations.

CONCLUSION

Our refined program theory proposes that in the context of easy access to an experienced and trusted case manager who provides comprehensive care while maintaining positive interactions with patients, the development of this relationship fosters the engagement of both individuals and yields positive outcomes when the following mechanisms are triggered: patients and clinicians feel supported, respected, accepted, engaged, and committed; and patients feel less anxious, more secure, and empowered to self-manage.

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.

Interventions to manage use of the emergency and urgent care system by people from vulnerable groups: a mapping review

Background

The NHS currently faces increasing demands on accident and emergency departments. Concern has been expressed regarding whether the needs of vulnerable groups are being handled appropriately or whether alternative methods of service delivery may provide more appropriate emergency and urgent care services for particular groups.

Objective

Our objective was to identify what interventions exist to manage use of the emergency and urgent care system by people from a prespecified list of vulnerable groups. We aimed to describe the characteristics of these interventions and examine service delivery outcomes (for patients and the health service) resulting from these interventions.

Review methods

We conducted an initial mapping review to assess the quantity and nature of the published research evidence relating to seven vulnerable groups (socioeconomically deprived people and families, migrants, ethnic minority groups, the long-term unemployed/inactive, people with unstable housing situations, people living in rural/isolated areas and people with substance abuse disorders). Databases, including MEDLINE and the Cumulative Index to Nursing and Allied Health Literature, and other sources were searched between 2008 and 2018. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. In addition, we searched for UK interventions and initiatives by examining press reports, commissioning plans and casebooks of ‘good practice’. We carried out a detailed intervention analysis, using an adapted version of the TIDieR (Template for Intervention Description and Replication) framework for describing interventions, and an analysis of current NHS practice initiatives.

Results

We identified nine different types of interventions: care navigators [three studies – moderate GRADE (Grading of Recommendations, Assessment, Development and Evaluations)], care planning (three studies – high), case finding (five studies – moderate), case management (four studies – high), front of accident and emergency general practice/front-door streaming model (one study – low), migrant support programme (one study – low), outreach services and teams (two studies – moderate), rapid access doctor/paramedic/urgent visiting services (one study – low) and urgent care clinics (one systematic review – moderate). Few interventions had been targeted at vulnerable populations; instead, they represented general population interventions or were targeted at frequent attenders (who may or may not be from vulnerable groups). Interventions supported by robust evidence (care navigators, care planning, case finding, case management, outreach services and teams, and urgent care clinics) demonstrated an effect on the general population, rather than specific population effects. Many programmes mixed intervention components (e.g. case finding, case management and care navigators), making it difficult to isolate the effect of any single component. Promising UK initiatives (front of accident and emergency general practice/front-door streaming model, migrant support programmes and rapid access doctor/paramedic/urgent visiting services) lacked rigorous evaluation. Evaluation should therefore focus on the clinical effectiveness and cost-effectiveness of these initiatives.

Conclusions

The review identified a limited number of intervention types that may be useful in addressing the needs of specific vulnerable populations, with little evidence specifically relating to these groups. The evidence highlights that vulnerable populations encompass different subgroups with potentially differing needs, and also that interventions seem particularly context sensitive. This indicates a need for a greater understanding of potential drivers for varying groups in specific localities.

Limitations

Resources did not allow exhaustive identification of all UK initiatives; the examples cited are indicative.

Future work

Research is required to examine how specific vulnerable populations differentially benefit from specific types of alternative service provision. Further exploration, using primary mixed-methods data and potentially realist evaluation, is required to explore what works for whom under what circumstances. Rigorous evaluation of UK initiatives is required, including a specific need for economic evaluations and for studies that incorporate effects on the wider emergency and urgent care system.

Funding

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