Abstract
Background: Older adults receive care from multiple health care providers and across sectors, making it difficult to coordinate care. Ineffective care coordination leads to poor health outcomes, greater service use, and increased system costs. One proposed solution to better integrate care across the system is through the implementation of a care manager role - someone to organize and oversee care. Based on previous research, we know that one point of contact for older adults and caregivers; and one person responsible for care planning and coordination, is the best approach. However, implementation of this type of role in a complex system is difficult and has resulted in many different iterations leading to a lack of common understanding of the scope of the role. This study aims to understand variations in the implementation of care manager roles across the system, to identify foundational skills and functions related to the role.
Approach: A qualitative approach was used to gather in-depth information about the day-to-day role and function of care managers. The interview guide was co-created with health care providers, patients, and caregiver partners. Interviews were conducted with individuals in various care manager roles across the system, or, with health care providers who work with care managers as part of their role. Interview participants were recruited through different primary care, and home and community care organizations across Southwestern Ontario. Interviews lasted between 30-45minutes, were audio-recorded and transcribed. Data were uploaded to NVivo 2, and analyzed using a line-by line emergent coding approach.
Results: In total, 0 individuals participated in in-depth interviews. Several key themes emerged, including: the need to establish better accountability for care managers; the need to prioritize person-centered care; and the importance of integrating the role of a care manager with primary care and community care resources. All health care provider participants identified the existing lack of responsibility for a patient care plan as a barrier to quality integrated care. To promote continuity and personalization of care, it was stressed that each patient should have one designated care manager who prioritizes relationship-building to better understand the patient physical, mental, and social needs. Several participants emphasized the role of care managers in both system navigation and implementation of services. The data highlighted that individuals in these roles must be connected to primary care and have an in-depth understanding of available community resources. Providers also discussed the resulting confusion of having multiple care managers involved in the care of one individual, leading to poor experiences, and missed opportunities to integrate care.
Implications: Information from this study is critical in understanding the current complexities around care manager roles across the system. We will build on this preliminary work, in an effort to better integrate primary and home and community care for older adults, through an integrated model of home-based primary care.