Understanding the challenges to implementing case management for people with dementia in primary care in England: a qualitative study using Normalization Process Theory

BMC Health Services Research

Louise Robinson³  Jill Manthorpe²  Steve Iliffe¹  Chris Fox⁴  Carolyn Chew-Graham⁵  Katie Brittain³  Marie Poole³  Claire Bamford³ 

[1] Department of Primary Care and Population Health, University College London, Royal Free Campus, Rowland Hill St, London NW3 2PF, UK;Social Care Workforce Research Unit, King’s College London, Strand, London WC2R 2LS, UK;Institute of Health and Society, Newcastle University, Baddiley Clark Building, Richardson Road, Newcastle NE2 4AX, UK;Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK;Research Institute, Primary Care and Health Sciences, Keele University, Keele ST5 5BG, Staffordshire, UK

关键词: Normalization Process Theory;    Primary care;    Carers;    Patients;    Case management;    Dementia;   

Others  :  1092213
DOI  :  10.1186/s12913-014-0549-6

 received in 2014-08-15, accepted in 2014-10-24,  发布年份 2014

【 摘 要 】

Background

Case management has been suggested as a way of improving the quality and cost-effectiveness of support for people with dementia. In this study we adapted and implemented a successful United States’ model of case management in primary care in England. The results are reported elsewhere, but a key finding was that little case management took place. This paper reports the findings of the process evaluation which used Normalization Process Theory to understand the barriers to implementation.

Methods

Ethnographic methods were used to explore the views and experiences of case management. Interviews with 49 stakeholders (patients, carers, case managers, health and social care professionals) were supplemented with observation of case managers during meetings and initial assessments with patients. Transcripts and field notes were analysed initially using the constant comparative approach and emerging themes were then mapped onto the framework of Normalization Process Theory.

Results

The primary focus during implementation was on the case managers as isolated individuals, with little attention being paid to the social or organizational context within which they worked. Barriers relating to each of the four main constructs of Normalization Process Theory were identified, with a lack of clarity over the scope and boundaries of the intervention (coherence); variable investment in the intervention (cognitive participation); a lack of resources, skills and training to deliver case management (collective action); and limited reflection and feedback on the case manager role (reflexive monitoring).

Conclusions

Despite the intuitive appeal of case management to all stakeholders, there were multiple barriers to implementation in primary care in England including: difficulties in embedding case managers within existing well-established community networks; the challenges of protecting time for case management; and case managers’ inability to identify, and act on, emerging patient and carer needs (an essential, but previously unrecognised, training need). In the light of these barriers it is unclear whether primary care is the most appropriate setting for case management in England. The process evaluation highlights key aspects of implementation and training to be addressed in future studies of case management for dementia.

【 授权许可】

   
2014 Bamford et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]World Alzheimer Report 2011. The benefits of early diagnosis and intervention. Alzheimer’s Society, London; 2011.
• [2]Richards DA, Hill JJ, Gask L, Lovell K, Chew-Graham C, Bower P, Cape J, Pilling S, Araya R, Kessler D, Bland JM, Green C, Gilbody S, Lewis G, Manning C, Hughes-Morley A, Barkham M: Clinical effectiveness of collaborative care for depression in UK primary care (CADET): cluster randomised controlled trial. BMJ 2013, 347:f4913.
• [3]Coupe N, Anderson E, Gask L, Sykes P, Richards D, Chew-Graham C: Facilitating professional liaison in collaborative care for depression in UK primary care; a qualitative study utilising normalisation process theory. BMC Fam Pract 2014, 15(1):78. BioMed Central Full Text
• [4]Challis D, Chesterman J, Luckett R, Stewart K, Chessum R: Care Management in Social and Primary Health Care: The Gateshead Community Care Scheme. Ashgate, Burlington; 2002.
• [5]Clark P, Bass D, Looman W, McCarthy C, Eckert S: Outcomes for patients with dementia from the Cleveland Alzheimer’s managed care demonstration. Aging Ment Health 2004, 8(1):40-51.
• [6]Pimouguet C, Lavaud T, Dartigues JF, Helmer C: Dementia case management effectiveness on health care costs and resource utilization: a systematic review of randomized control trials. J Nutr Health Aging 2010, 14(8):669-676.
• [7]Somme D, Trouve H, Dramé M, Gagnon D, Couturier Y, Saint-Jean O: Analysis of case management programs for patients with dementia: A systematic review. Alzheimers Dement 2012, 8(5):426-436.
• [8]Tam-Tham H, Cepoiu-Martin M, Ronksley PE, Maxwell CJ, Hemmelgarn BR: Dementia case management and risk of long-term care placement: a systematic review and meta-analysis. Int J Geriatr Psychiatry 2013, 28(9):889-902.
• [9]Living with Dementia: the national dementia stategy. Department of Health, London; 2009.
• [10]Improving services and support for people with dementia. The Stationery Office, London; 2007.
• [11]The £20 Billion Question - an inquiry into improving lives through cost effective dementia services [http://www.insidehousing.co.uk/Journals/1/Files/2011/7/12/Dementia.pdf] webciteIn 2013. available from http://www.insidehousing.co.uk/Journals/1/Files/2011/7/12/Dementia.pdf
• [12]Callahan CM, Boustani MA, Unverzagt FW: Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial. J Am Med Assoc 2006, 295(18):2148-2157.
• [13]Waugh A, Austin A, Manthorpe J, Fox C, Stephens B, Robinson L, Iliffe S: Designing a complex intervention for dementia case management in primary care. BMC Fam Pract 2013, 14(1):101. BioMed Central Full Text
• [14]Iliffe S, Waugh A, Poole M, Bamford C, Brittain K, Chew-Graham C, Fox C, Katona C, Livingston G, Manthorpe J, Steen N, Stephens B, Hogan V, Robinson L: The effectiveness of collaborative care for people with memory problems in primary care: results of the CAREDEM case management modelling and feasibility study.Health Technol Assess 2014, 18(52).
• [15]Jansen AP, van Hout HP, Nijpels G, Rijmen F, Droes RM, Pot AM, Schellevis FG, Stalman WA, van Marwijk HW: Effectiveness of case management among older adults with early symptoms of dementia and their primary informal caregivers: a randomized clinical trial. Int J Nurs Stud 2011, 48(8):933-943.
• [16]Minkman MMN, Ligthart SA, Huijsman R: Integrated dementia care in the Netherlands: a multiple case study of case management programmes. Health Soc Care Community 2009, 17(5):485-494.
• [17]Gustafsson M, Kristensson J, Holst G, Willman A, Bohman D: Case managers for older persons with multi-morbidity and their everyday work - a focused ethnography. BMC Health Serv Res 2013, 13(1):496. BioMed Central Full Text
• [18]Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M: Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008, 337:a1655.
• [19]O′Cathain A, Thomas KJ, Drabble SJ, Rudolph A, Hewison J: What can qualitative research do for randomised controlled trials? A systematic mapping review. BMJ Open 2013, 3(6):e002889.
• [20]May C, Finch T: Implementing, embedding, and integrating practices: an outline of normalization process theory. Sociology 2009, 43(3):535-554.
• [21]McEvoy R, Ballini L, Maltoni S, O'Donnell C, Mair F, MacFarlane A: A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implement Sci 2014, 9(1):2. BioMed Central Full Text
• [22]Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, Finch T, Kennedy A, Mair F, O'Donnell C, Ong BN, Rapley T, Rogers A, May C: Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med 2010, 8(1):63. BioMed Central Full Text
• [23]Strong PM: The Ceremonial Order of the Clinic: Parents, Doctors, and Medical Bureaucracies. Routledge and Kegan Paul, London; 1979.
• [24]Verkade PJ, Van Meijel B, Brink C, Van Os-Medendorp H, Koekkoek B, Franke AL: Delphi-research exploring essential components and preconditions for case management in people with dementia. BMC Geriatr 2010, 10(54):1-11.
• [25][http:/ / www.intechopen.com/ books/ health-management/ the-prisma-france-study-is-there-a- way-to-measure-implementation-of-in tegration-in-different-countri] webcite Trouve HVA, Hebert R, Somme D: The PRISMA France Study: Is There a Way to Measure Implementation of Integration in Different Countries? In Health Management. Edited by Smigorski K. Sciyo; 2010. Available from: .
• [26]Koch T, Iliffe S, Manthorpe J, Stephens B, Fox C, Robinson L, Livingston G, Coulton S, Knapp M, Chew-Graham CA, Katona C: The potential of case management for people with dementia: a commentary. Int J Geriatr Psychiatry 2012, 27(12):1305-1314.
• [27]Goodman C, Drennan V, Davies S, Massey H, Gage H, Scott C: Nurses as case managers in primary care: the contribution to chronic disease management. NIHR, Southampton; 2010.
• [28]Tucker S, Wilberforce M, Brand C, Abendstern M, Challis D: All things to all people? The provision of outreach by community mental health teams for older people in England: findings from a national survey. Int J Geriatr Psychiatry 2014, 29(5):489-496.
• [29]Vernooij-Dassen M, Moniz-Cook E: Raising the standard of applied dementia care research: addressing the implementation error. Aging Ment Health 2014, 18(7):809-814.
• [30]van der Roest HG, Meiland FJM, Comijis HC, Derksen E, Jansen APD, van Hout HPJ, Jonker C, Droes RM: What do community-dwelling people with dementia need? A survey of those who are known to care and welfare services. Int Psychogeriatr 2009, 21(5):949-965.
• [31]Miranda-Castillo C, Woods B, Orrell M: The needs of people with dementia living at home from user, caregiver and professional perspectives: a cross-sectional survey. BMC Health Serv Res 2013, 13(1):43. BioMed Central Full Text
• [32]Chiatti C, Masera F, Rimland J, Cherubini A, Scarpino O, Spazzafumo L, Lattanzio F: The UP-TECH project, an intervention to support caregivers of Alzheimer’s disease patients in Italy: study protocol for a randomized controlled trial. Trials 2013, 14(1):155. BioMed Central Full Text