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

Abstract

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.

Frequent attenders' experiences of encounters with healthcare personnel: A systematic review of qualitative studies

“…according to the patient´s needs have been found to reduce the frequency of healthcare visits (Hudon et al, 2020). Therefore, a more patient-centered approach to frequent attenders´treatment and service planning may be beneficial.…”

“…Previous interventions targeted at frequent attenders have yielded inconsistent results, and there is no clear evidence that they directly reduced frequent attenders' attendance rates (Haroun et al, 2016). However, case management interventions in which services are “customized” according to the patient´s needs have been found to reduce the frequency of healthcare visits (Hudon et al, 2020). Therefore, a more patient‐centered approach to frequent attenders´ treatment and service planning may be beneficial.…”

“…Patient‐physician relationships based on collaboration have been found to reduce frequent attenders' healthcare costs (Ganguli, Thompson, & Ferris, 2017), and low satisfaction with care is associated with frequent attendance (Koskela, Ryynänen, & Soini, 2010). In their literature review, Hudon et al (2020) examined how case management interventions improve outcomes for frequent attenders. They noted that the quality of the relationship between the case manager and the frequent attender is essential regarding the successfulness of case management.…”

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

“…In PriCARE, 2 literature reviews on case management were conducted: a systematic review by the academic research team 22 and a realist synthesis by the research team engaging stakeholders in the steering committee, including decision makers, clinicians, and patient partners. 23 Both reviews were summarized and shared with stakeholders. (6) Choose or Construct a Theoretical Framework A theoretical framework emerging from the literature review helps elaborate research questions and points of emphasis.…”

Towards Better Health, Social, and Community-Based Services Integration for Patients with Chronic Conditions and Complex Care Needs: Stakeholders’ Recommendations

“…In a context where we must contemplate solutions to meet the challenges encountered in following up with these patients [ 4 , 15 , 16 , 17 ], a summit gathering a critical mass of key stakeholders was organized as part of the Quebec Strategy for Patient-Oriented Research (SPOR) Support Unit for Public and Patient-Oriented Research and Trials (SUPPORT) demonstration project [ 18 ]. The aim of this study is to report on the issues relating to patients with complex care needs and on the recommendations advanced during the summit in an effort to better integrate health, social, and community-based services for patients with chronic conditions and complex care needs.…”