The implementation of case management in primary care teams: a qualitative study using Normalisation Process Theory

Problem

Case management has been identified as a way of improving the complex care required by people with multiple health and social care needs. It can be implemented with an individual case manager or via a multidisciplinary team (MDT). A case management intervention to improve the care of people at high risk of unplanned admission to hospital was introduced by Northumberland Clinical Commissioning Group in 2013.

Approach

This study aims to explore the experiences of healthcare professionals who implemented the MDT led case management programme. Qualitative methods of focus groups and semi-structured interviews were used to explore views and experiences of case management delivered by a MDT. Transcripts were analysed initially using thematic analysis and emerging themes were mapped onto the framework of Normalisation Process Theory.

Findings

MDTs had varied membership and a total of 53 healthcare professionals participated. Nine focus groups and 5 semi-structured individual interviews. These were conducted with different members of the MDT and included Geriatricians, pharmacists, GPs, district nurse, practice nurses, administrators and social workers . Participants were generally supportive of the case management intervention and thought it made sense to proactively plan to keep vulnerable people at home (coherence) though some participants did express confusion and disagreement about which patients should be regarded as ‘high risk’. High levels of investment (cognitive participation) were reported by the majority of participants in terms of the time devoted to implementation. For professionals who worked across different primary care teams there was evidence that some teams were more motivated and engaged. The key barriers to implementation were reported to be time, lack of direction and the changing nature of relationships with patients (collective action). Finally, participants identified a number of modifications they had made to the programme and discussed their strong desire to see evidence that their investment in time and resources had been worthwhile (reflexive monitoring) however they also struggled to identify which outcomes would be appropriate in this complex, real world intervention.

Consequences

Participants displayed high levels of commitment to make MDT case management successful. . They believed it did lead to better patient care but was costly in terms of time and resources. Greater clarity about which patients should be included and a reduction in the administration were identified as ways of improving the intervention.