Strategies to engage general practitioners in integrated care for frail older persons : a realist approach

Abstract

Case management is one of the interventions believed to foster integrated clinical care for people with complex care needs, as is often the case of frail, community-dwelling older persons. Evidence shows that one of the cornerstones of case management is strong inter-professional collaboration between the case manager and the beneficiary’s own general practitioner (GP). Despite the positive outcomes found in many studies in terms of higher quality of care delivery and users’ satisfaction, a constant finding is that the beneficiary’s GPs’ engagement in the case management process is generally poor. The aim of this study is to investigate how, why and for which general practitioners strategies to engage them are successful – or not. Methods: The study is an ongoing action–research framed by a realist approach and using mixedmethods. Firstly, a realist synthesis was performed, in which explanatory candidate theories about successful case management were yielded. Secondly, results of an ongoing evaluation study including similar interventions in Belgium will be used to refine these theories. Thirdly, the refining and testing process will be continued by the means of a multiple-embedded case study of three case management projects. Data to be collected will focus on how the intervention is thought to produce results by stakeholders delivering, receiving, participating in case management at different levels of the local system, including the general practitioners (by the means of questionnaires, documentary analysis, interviews and focus groups). The analysis will be framed by the realist equation context-mechanism-outcomes (CMO) configurations explaining why general practitioners engage in this type of collaborative practice, under which conditions and to what extent. Fourthly, the results will be submitted twice a year to case managers and GPs during realist interviews, in order to validate and refine the CMO configurations and middle-range theories found in the previous steps. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-116971 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Results: (Intermediate and expected) The realist synthesis and the first elements of the ongoing study found that the overarching theory of change likely to explain the effectiveness of case management for this population was composed of a set of six sequential steps. Each of the steps could not be achieved if the previous one had not been adequately addressed. In each step interprofessional collaboration, especially with the GP, was found of critical importance. In the next steps of the study, we have planned to test and develop this theory further by focusing on the strategies to engage successfully GPs in case management interactions. These successful interactions are expected to foster positive outcomes in frail older persons in terms of quality of care improvement and even in terms of “hard outcomes”, such as delaying institutionalisation and functional status. Moreover, it is expected that this action learning could also have an impact on the local system of primary care, in changing the perceptions of the role of other professionals in a given context. Discussion: The realist approach, dealing with whole-system thinking, seems a methodology particularly relevant to study complex social situations such as GPs’ involvement in case management of frail elderly. Engaging in a process of action-research with the stakeholders by submitting them the CMO configurations, we should be able to (1) identify and test a middle-range theory; (2) improve inter-professional collaboration by the means of encouraging GPs’ reflection about their own collaborative practices; (3) identify possible leverage points to address the constraints identified, while encouraging enabling factors. Conclusion: While it is unusual for researchers and clinicians to work together in such a way, we hope that this approach will contribute to the inter-professional dialogue through the lens of successful mechanisms operating in case management interventions. Moreover, even if policy makers are often more interested in the overall effect and efficiency of case management and the economy of what returns were achieved from the resources devoted to it, we also hope to be able to engage them at a later stage in the discussion about the clarification of the mechanisms and contexts likely to improve inter-professional collaboration, and by this means lead to better quality of care for the beneficiaries of the interventions.