Khanassov, Vladimir (2014). Case Management Targeting Patients With Dementia In Community-Based Primary Health Care: Barriers to Implementation McGill Family Medicine Studies Online, 09: e02.

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ABSTRACT

Case management (CM) designed for patients with dementia and their caregivers in Community-Based Primary Health Care (CBPHC) services demonstrated inconsistent results. One of the explanations of this phenomenon can be the barriers to CM implementation. Our objectives were (i) To examine the factors associated with the implementation of CM interventions in CBPHC; (ii) To identify the relationships between key outcomes of CM and barriers to implementation; (iii) To develop strategies to enhance its adoption by CBPHC practices.

Methods: We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in Medline, PsycInfo, Embase, the Cochrane Database and Database of Abstracts of Reviews of Effects (1995- up to August 2012). CM intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, cost-effectiveness, and other outcomes. Qualitative studies were used to examine barriers to CM implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the Configurational Comparative Method. The diffusion of innovation model was used to develop strategies to enhance CM adoption by CBPHC practices. The quality of included studies was assessed using the Mixed Methods Appraisal Tool.

Results: 43 studies were selected (31 quantitative and 12 qualitative). Overall, CM demonstrated a limited positive effect on: behavioural symptoms of dementia (mean effect size: 0.88) and length of hospital stay (mean effect size: 1.06) (for patients); as well as burden (mean effect size: 0.5) and depression (mean effect size: 0.68) (for caregivers). Various factors that can hinder or facilitate the adoption of CM were identified and organized according to the components of the diffusion of innovation model. Interventions that addressed a greater number of barriers to implementation resulted in more positive outcomes. Results of synthesis suggested that high CM intensity (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) was necessary and sufficient to produce positive clinical outcomes for patients and optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers. The characteristics of CM (intensity, caseload, and approach - proactive rather than reactive) need to be clarified before implementation. Case managers need specific skills to perform their role (e.g., good communication skills) and their responsibilities in CBPHC need to be clearly delineated.
Conclusions: Inconsistent results can be explained by the barriers to CM implementation. Clinicians and managers who implement CM in CBPHC should take into account: a high intensity of CM and effective communication between case managers and other CBPHC professionals/services. Lastly, strategies are proposed to enhance implementation of dementia CM in CBPHC.