Abstract
Background: This paper intends to develop discussions on methodological innovations in integrated care, by exploring how the use of a complex health system evaluation framework in a qualitative study can positively impact the understanding of the multitude of factors that shape the delivery of case management (CM) approaches in integrated care teams working with older people.
Approach: CM approaches to coordinating care have been posited as one possible means of improving experiences of person-centred integrated care for community dwelling older adults. However, CM programmes have been described as ‘complex interventions’ and a knowledge gap exists in relation to best practice models for older persons with complex health and social care needs. Evaluation efforts to date have been described as largely atheoretical and focusing on the clinical level, with a lack of focus on the dynamic interplay of macro (policy/structural) and meso (organisational) factors impacting on integrated care delivery and their relationship with the effective implementation of CM. To overcome this skewed focus, the application of a system-wide theoretical perspective is required. The purpose of this paper is to describe, how within a qualitative case study, the application of such a conceptual perspective can be used as a ‘blueprint’ or ‘sensitising tool’ to elucidate the interacting and underlying processes which impact upon the delivery of CM. The study can be categorised as a multiple, instrumental case study with both an exploratory and explanatory component. The units of analysis were professionals working in three heterogeneous Community Specialist Teams or Older People, delivering interventions as part of the National Integrated Care Programme for Older Persons in Ireland. The composite model utilised in the study was the Multi-level Health Innovation model (Chaudoir et al. 2013) and Ross et al’s (2011)’s categorisation of CM.
Findings: Findings point to the many advantages of utilising a composite model as a methodological framework to reveal an in-depth and nuanced understanding of the factors which impact the delivery of integrated care and CM. The framework guided formulation and specificity of the research questions and aims, as well as the iterative approach to data generation and analysis undertaken throughout. The use of Ross et al’s typology of CM revealed the significance of different intensities of CM, highlighting key distinctions between an Intensive-Advocacy and Clinical-Brokage model. The inter-relationship between how these distinctions have evolved and responded to dynamic geographical resources, organisational infrastructures and policy directives was revealed. Analysis also revealed the interacting impact of these macro and meso variables on both the processes and outcomes of person-centered integrated care and how such interactions may be more impactful for frail, socially isolated older people.
Implications: The paper underscores the importance of theory-driven and informed analysis in qualitative health care research and is of relevance to researchers and policy makers engaged in healthcare reform and design. The approach undertaken by the authors in the current paper, could be used as a template for other researchers evaluating integrated care and case management.
References
Chaudoir, et al. (2013) https://doi.org/10.1186/1748-5908-8-22
Ross et al (2011) https://assets.kingsfund.org.uk/f/256914/x/9374b758f1/case_management_2011.pdf