Implementation Of Case Management Research Articles

Case management: developing practice through action research

This article is a report of an action research study carried out with community nurses to help develop case management within their practice. Using action research principles, nurses reviewed and analysed their current practice and developed recommendations for further embedding case management as a means of supporting patients with complex care needs in their own homes. Findings indicate that a number of factors can influence the community nurse's ability to implement case management. These factors include approaches to case finding, availability of resources and interprofessional working. Important considerations for nurses were the influence of the context of care, the geographical location and the health needs of the local patient population, which meant that case management may need to be adapted to meet local circumstances.

P6.022 Results of the Global Fund Programmes Implementation on STI Diagnostics and Treatment Within Most-At-Risk Populations in Ukraine

Problem: Ukraine has the fastest HIV spread pace in Europe (221 806 people as of November 2012).Sexual HIV transmission mode has been dominant in Ukraine since 2008 (51%–sexual, 28%–parenteral).HIV/STI epidemic...

Case management the panacea for aged care

Aims: The aim of this study was to evaluate the influence of case management on family member or other caregivers involvement in residential aged care settings; staff?family relationships and family satisfaction with residential care. Method: This was a controlled before and after study involving pre and post intervention testing and comparison between intervention and control groups from two 30 bed rural high care residential aged care facilities. Staff from the intervention facility underwent case management training and resources were allocated to implement case management. General demographic information was collected about the family member and the residents. The Family Involvement Questionnaire and the Family Perception of Care Tool was used pre and post intervention to determine the level of family involvement and their perception of care provided. Results: Visiting levels increased in the intervention site but not the control site. No significant differences were found for the two sites over the two phases but increases were seen in correspondence, attendance at social activities, overseeing staff interactions, attendance at case conferences and rate of family member decision-making about treatments or care for the intervention site. The overall satisfaction with care and the relationships increased at the intervention site but the changes were not significant. Conclusion: Although there were no statistically significant results due to the sample size, there were positive changes at the intervention site. Case management is a potentially suitable model of care in the aged care setting.

Geographic Variation of Benign Lung Disease in the US: Implications for Lung Cancer Screening

Frequent users of emergency departments (EDs) are a relatively small group of vulnerable patients accounting for a disproportionally high number of ED visits. Our objective is to perform a systematic review of the type and effectiveness of interventions to reduce the number of ED visits by frequent users.We searched MEDLINE, EMBASE, CINAHL, PsychINFO, the Cochrane Library, and ISI Web of Science for randomized controlled trials, nonrandomized controlled trials, interrupted time series, and controlled and noncontrolled before-and-after studies describing interventions targeting adult frequent users of EDs. Primary outcome of interest was the reduction in ED use. We also explored costs analyses and various clinical (alcohol and drug use, psychiatric symptoms, mortality) and social (homelessness, insurance status, social security support) outcomes.We included 11 studies (3 randomized controlled trials, 2 controlled and 6 noncontrolled before-and-after studies). Heterogeneity in both study designs and definitions of frequent users precluded meta-analyses of the results. The most studied intervention was case management (n=7). Only 1 of 3 randomized controlled trials showed a significant reduction in ED use compared with usual care. Six of the 8 before-and-after studies reported a significant reduction in ED use, and 1 study showed a significant increase. ED cost reductions were demonstrated in 3 studies. Social outcomes such as reduction of homelessness were favorable in 3 of 3 studies, and clinical outcomes trended toward positive results in 2 of 3 studies.Interventions targeting frequent users may reduce ED use. Case management, the most frequently described intervention, reduced ED costs and seemed to improve social and clinical outcomes. It appears to be beneficial to patients and justifiable for hospitals to implement case management for frequent users in the framework of a clear and consensual definition of frequent users and standardized outcome measures.

Die Case-Management-basierte Betreuung von Brustkrebspatientinnen: Ergebnisse einer Befragung beteiligter ärztlicher und nichtärztlicher Netzwerkpartner

Ziel der Studie: Brustkrebspatientinnen benotigen im Regelfall eine mehrfach aufeinanderfolgende und wechselnde stationare, teilstationare und ambulante Behandlung von langer Dauer. Die bedarfsgerechte Versorgung erfordert eine sektorenubergreifende Vernetzung aller an Diagnostik, Therapie, Rehabilitation und Nachsorge beteiligten multiprofessionellen Personen. Eine Methode zur Forderung der Integration des Behandlungsprozesses sowie – daraus resultierend – zur Effektivitats- und Effizienzsteigerung kann das Konzept Case Management darstellen. Voraussetzung fur eine effektive Umsetzung des Case Managements und damit Ausgangspunkt der vorliegenden Befragung ist ein gut funktionierendes Netzwerk. Im Rahmen einer Gesamtevaluation wurde vor dem Hintergrund des Innovations- und Optimierungspotenzials von Case Management einerseits sowie des Vorliegens nur weniger empirischer Daten andererseits die vorliegende Befragung von Kooperationspartnern eines transsektoralen Netzwerkes des Integrierten Versorgungsmodells „mammaNetz“ fur Frauen mit Mammakarzinom, das auf der Methode des Case Managements basiert, durchgefuhrt. Methodik: Arztliche und nichtarztliche Netzwerkpartner der Begleitstelle (N=168) wurden zu verschiedenen Aspekten der Kooperation mit jeweils unterschiedlichen Fragebogenversionen postalisch befragt. Beide Versionen enthielten ebenfalls identische Items, diese wurden miteinander verglichen. Ergebnisse: Die Rucklaufquote bei den arztlichen Netzwerkpartnern liegt bei 59% (n=35) − wobei sich ausschlieslich niedergelassene Arzte an der Befragung beteiligt haben − bei den nichtarztlichen Netzwerkpartnern bei 60% (n=66). Arztliche Netzwerkpartner beurteilen die Kooperation mit der Begleitstelle hinsichtlich des Informationsaustauschs etwas positiver (66%) als die nichtarztlichen Netzwerkpartner (59%). Arztliche Netzwerkpartner stehen signifikant haufiger in Kontakt mit der Begleitstelle und sehen signifikant haufiger Vorteile in der Zusammenarbeit fur die eigene Praxis/Einrichtung (jeweils p=0,001) als die nichtarztlichen Netzwerkpartner. Insgesamt deuten die Ergebnisse darauf hin, dass sowohl arztliche als auch nichtarztliche Netzwerkpartner die Arbeitsweise und das methodische Konzept der Begleitstelle fur sinnvoll erachten. Schlussfolgerung: Die Realisierung eines interdisziplinaren Unterstutzungsprozesses fur Patientinnen mit Mammakarzinom erfordert eine gute Zusammenarbeit von Netzwerkpartnern, Case Managerinnen und Patientinnen. Im Rahmen einer Folgeuntersuchung mit dem Ziel einer vertiefenden Prozessevaluation sollten nichtarztliche Netzwerkpartner in weitere professionsspezifische Untergruppen unterteilt werden. Daraus konnten Interventionen, die auf spezifische Berufsgruppen zugeschnitten sind, abgeleitet werden.

Significance of a case-management-led, multidisciplinary team approach in the treatment of prostate cancer.

81 Background: Prostate cancer is the most commonly diagnosed non-skin malignancy within the Madigan Health System. Madigan recognized the burden of prostate cancer and began a process improvement initiative on June 1, 2009 to provide patient-focused multi-disciplinary counseling and consultative service to patients newly and previously diagnosed with prostate cancer. Methods: The multi-disciplinary team and Prostate Cancer Pathway are led by a RN Case Manager in collaboration with the Departments of Urology, Radiation Oncology and Hematology Oncology. Patients enrolled in the pathway are case managed in accordance with NCCN evidenced based guidelines and have access to all specialty services contained within Madigan, the U.S. Army Western Region Medical Command, and the Tricare referral network. Major program goals of the Prostate Cancer Pathway are to bolster patient surveillance to levels congruent with national evidenced based guidelines, and to promote efficient use of clinic time by selectively scheduling patients based on acuity. The aims of the pathway are primarily accomplished through case management. Results: Prior to the implementation of case management, prostate cancer patients averaged 3.3 appointments per annum. Per NCCN guidelines, the average number of annual visits is 2.8 during the initial 5 year post treatment phase. Upon completion of 18 consecutive months of case management, program metrics indicate that the average number prostate cancer visits decreased to 2.9 appointments per year. Concurrently, case management screening impacted scheduled visits; resulting in 485 avoided appointments for reasons of clinical stability and favorable patient reported quality of life indicators. As a result of enhanced access, the total number of post program deployment prostate cancer patients increased by approximately 15%. Conclusions: Initial identified metrics indicate that prostate cancer case management can considerably impact surveillance rates and clinic efficiency and may be disseminated to additional populations. The case management led model has recently been utilized to create a similar pathway to address testicular cancer within the Madigan Health System.

Smart mobile support for HTML5-based real-time Community Case Management System Development

In this paper, we take advantage of the characteristics of mobile smartphones can be serviced without the constraints of time and space, and Study was developed by a variety of mobile services were done in a traditional offline can be implemented in real-time Case Management Community. To this end, in addition to general PC/laptop, smart mobile until the configuration interface provide the same environment for HTML5 Web Switching and Optimal Network on the same device-specific browser Size to the implementation of the next generation of Web standards, HTML5-based integrated case management Web and Mobile Web. Hybrid App Development OS supports various kinds of smart devices based on SenchaTouch Mobile Framework between the server real-time synchronization and message through the implementation of the Push Notification function, administrators and guardians real-time two-way communication between the subjects is a real-time implementation of the system was implemented Case Management Community.

Impact of Case Management of Chronic Hepatitis C (HCV) Treatment in a State Medicaid Program

Purpose: Antiviral therapy for chronic HCV is prolonged with significant side effects and costs which can limit adherence and effectiveness. Medicaid population has socioeconomic challenges that can reduce adherence which is a critical component for successful treatment of HCV infection. The purpose of this study was to document impact of case management on treatment effectiveness in a fee for service Medicaid program in a rural state. Methods: Data on Medicaid patients with HCV on genotype-specific treatment were actively tracked by Arkansas Medicaid. The 2009 AASLD Guidelines for chronic HCV infection treatment criteria were used to guide treatment and prior authorization was required for antiviral treatment based on a patient's clinical characteristics and response to therapy. The HCV clinical criteria applied to both new patients to therapy as well as patients who were currently receiving HCV drug therapy. Prior approval was mandated for all requests for treatment. Requests to extend therapy beyond stated durations for each genotype, was reviewed on a case-by-case basis. Results: 170 patients were referred for treatment as of Jan 2011. 15 were denied treatment based on entry criteria. Another 11 patients did not start treatment or switched insurance. Of the 144 patients followed by Arkansas Medicaid, a genotype was available on all (100%) and a baseline viral load was available on 138 (96%) patients. 59 patients had cessation of treatment due to various reasons. 42 completed treatment and 43 are actively being treated. A 12 week viral load is one of the indicators included in Medicare's 2009 Physician Quality Reporting Initiative. There were 104 patients who eligible for a 12 week viral load which was checked in 84 (81%) of patients. Prior to implementation of case management, 146 unique recipients were treated between 09-08 to 09-09 at per capita cost of $10,660. Since then, between 09-09 and 09-10, 134 unique recipients were treated at a cost of $9,264 per recipient, leading to a cost savings of over $300,000. There were 15 denials leading to more than $400,000 in cost avoidance. There were further savings from proper therapy management, e.g., not letting the therapy extend past recognized guidelines, denials of sporadic medication refills, etc. Conclusion: Antiviral therapy can be compromised by gaps in dosing, and costs can escalate due to persistent therapy in unresponsive patients, and initiation of care for inappropriate patients. Supervised care can identify gaps in care and save healthcare dollars. The study is limited by a small sample size and more data is needed before the concept of managed care could be applied to other state Medicaid programs.Table: Table. Early viral response

Identification of facilitators and barriers to participation in weight gain prevention research by African American girls

Objective The purpose of the current study is to describe the development, implementation, and success of recruitment and adherence strategies of 303 African American preadolescent girls and their primary caregiver in the Girls health Enrichment Multi-site Studies (GEMS) program. Methods A socio-ecologic model was used to guide selection and implementation of recruitment and retention strategies which were continuously monitored and revised in response. Strategy mode and frequency associated with program enrollment, engagement, and retention were analyzed. Results Successful recruitment approaches included radio messages (23.1%), school fliers (20.1%), and friend referral (15%). Initially 463 potential participants responded, 320 girls were screened, and 303 enrolled. Significant increases in participant accrual were observed between Wave 4 (n = 28) and Wave 5 (n = 91) after using a team recruitment approach. Implementing case management strategies and providing make-up sessions also served to keep participants current and engaged in the program. In year 2, community field trips replaced the more structured sessions providing participants with experiential learning opportunities. Overall intervention attendance rates ranged from 79.7% to 90.5% among waves. Further, 75.9% and 80.2%, respectively, of participants attended 1-year and 2-year follow-ups. Conclusion Multiple recruitment strategies and flexible, responsive approaches to recruitment and retention guided by the socio-ecologic model facilitated optimal implementation of an intervention for preadolescent girls. Through the application of the socio-ecologic model researchers and program leaders will be able to identify strategies to enhance the probability of successful outcomes.

Effectiveness of Interventions Targeting Frequent Users of Emergency Departments: A Systematic Review

Frequent users of emergency departments (EDs) are a relatively small group of vulnerable patients accounting for a disproportionally high number of ED visits. Our objective is to perform a systematic review of the type and effectiveness of interventions to reduce the number of ED visits by frequent users. We searched MEDLINE, EMBASE, CINAHL, PsychINFO, the Cochrane Library, and ISI Web of Science for randomized controlled trials, nonrandomized controlled trials, interrupted time series, and controlled and noncontrolled before-and-after studies describing interventions targeting adult frequent users of EDs. Primary outcome of interest was the reduction in ED use. We also explored costs analyses and various clinical (alcohol and drug use, psychiatric symptoms, mortality) and social (homelessness, insurance status, social security support) outcomes. We included 11 studies (3 randomized controlled trials, 2 controlled and 6 noncontrolled before-and-after studies). Heterogeneity in both study designs and definitions of frequent users precluded meta-analyses of the results. The most studied intervention was case management (n=7). Only 1 of 3 randomized controlled trials showed a significant reduction in ED use compared with usual care. Six of the 8 before-and-after studies reported a significant reduction in ED use, and 1 study showed a significant increase. ED cost reductions were demonstrated in 3 studies. Social outcomes such as reduction of homelessness were favorable in 3 of 3 studies, and clinical outcomes trended toward positive results in 2 of 3 studies. Interventions targeting frequent users may reduce ED use. Case management, the most frequently described intervention, reduced ED costs and seemed to improve social and clinical outcomes. It appears to be beneficial to patients and justifiable for hospitals to implement case management for frequent users in the framework of a clear and consensual definition of frequent users and standardized outcome measures.

Implementation of case management in long-term conditions in England: Survey and case studies

Our aim was to describe the current provision of case management arrangements in primary care for people with long-term conditions in England and identify the extent and nature of self-care support services within it. Cross-sectional survey of primary care trusts (PCTs) in England and four case studies using semi-structured interviews and focus groups. Services were predominantly nurse-led, typically by community matrons, and delivered on a geographical basis. Often multiple arrangements existed within a PCT but integration of services with local authority adult social care was not widespread. A range of self-care support services were utilized and often tuition was provided by case managers to patients in their own homes. Assessment, care coordination and direct support to patients were the principal tasks. Often care plans were limited to primary care services and did not include service costings. Links with nurse-led services within PCTs were evident but operational links with adult social care were poorly developed. This is consistent with previous research relating to the introduction of care management in social services in England which also resulted in a plethora of organizational arrangements. Case management for patients with long-term conditions is at an early stage of development. Effective links with a range of local services are required if care plans are going to be comprehensive.

Practice-based depression case management in primary care: a qualitative study on family doctors' perspectives

Case management provided by health care assistants (HCAs) is effective in improving primary care for depressive patients. Little is known on the implementation-related aspects of case management performed in small family practices. To explore family doctors' perspectives on clinical and organizational aspects of implementation of case management and perceived practice-related aspects associated with patient care after 1 year's experience of HCAs providing case management for depressive patients in their practices. This qualitative study was nested in a cluster-randomized trial on case management provided by practice-based HCAs for patients with major depression in Germany. We used semi-structured interview guides and performed audio-taped interviews with family doctors. Full transcription and thematic content analysis were carried out. Twenty-three family doctors were interviewed. The family doctors perceived case management as beneficial to patients and reported that it improved their consultation styles and doctor-patient relationships. They implemented case management elements into their everyday day work using 'concrete', 'subsumed' or 'progressive' implementation styles. Family doctors perceived practice-based case management by HCAs as beneficial for patient care. Different implementation styles may be appropriate, depending on the health care setting, and this requires further evaluation.

Die Case-Management-basierte Betreuung von Brustkrebspatientinnen: Ergebnisse einer Befragung beteiligter ärztlicher und nichtärztlicher Netzwerkpartner

Breast cancer patients are as a rule in need of a multiple sequential in-patient, day-patient and out-patient permanent treatment. The required care demands a trans-sectoral networking of all multi-professional persons involved in diagnostics, therapies, rehabilitation and aftercare. A method to develop the integration of treatment processes, as well as thereby resulting in increased effectiveness and efficiency, can constitute the concept of case management. A prerequisite for an effective implementation of case management and thus the starting point of the present survey is a well-functioning network encompassing optimal cooperation. Within the framework of the evaluation of the case management-based integrated care model "mammaNetz" for women with mamma carcinoma as a whole and against the background of the potential for innovation and improvement of case management on the one hand as well as the existence of only few empirical data otherwise, the present survey of members of a trans-sectoral network of the service centre was accomplished. Medical and non-medical networking partners of the service centre (N=168) were questioned by regular mail about different aspects of the cooperation. Identical items in both surveys were compared. The return rate for the medical networking partners is about 59% (n=35), whereby only medical network partners in private practice participated in the survey. For the non-medical networking partners about 60% (n=66) participated. Medical networking partners assess the cooperation with the service centre in reference to the exchange of information slightly more positively (66%) than the non-medical networking partners (59%). Medical networking partners are in significantly more frequent contact with the service centre and see in the cooperation significantly more advantages for their own office/facility (each with p=0.001) than non-medical networking partners. Overall the results suggest that medical as well as non-medical networking partners consider the functioning and the methodical concept of the service centre to be reasonable. The implementation of an interdisciplinary process of support for patients with mamma carcinoma necessitates a good cooperation between networking partners, case managers and patients. Within the framework of a follow-up survey with the objective of a deeper process evaluation, non-medical networking partners should be divided into further professional specific subcategories. In this manner interventions that are fitted to specific occupational groups can be derived.

The care of patients with complex long-term conditions

The innovation of case management has been a controversial issue since nationwide implementation in 2005. The long-term condition (LTC) agenda remains prominent within all primary and secondary care services and the importance of patient-centred care is paramount. This article outlines the development and implementation of case management within a case study of a patient with the LTC chronic obstructive pulmonary disease. Key topics such as holistic care, individualized care planning and quality of life are reviewed to give awareness of the success of case management within the care of patients with complex LTCs.

Para-social work to address most vulnerable children in sub-Sahara Africa: A case example in Tanzania

Addressing the needs of the most vulnerable children is a universal challenge, particularly in developing countries lacking infrastructure of social welfare services, adequately trained workforce and educational programs. This article describes training and utilization of para-social workers to the social service needs of children and families. These supervised para-professional community based staff and volunteers can fill gaps in serving the needs of children and families, particularly where social welfare systems are undeveloped or severely stretched. We present the development of one such program as a case study, the Social Work Partnership for Orphans and Vulnerable Children in Tanzania. A competency-based training model includes an introductory workshop, a six month-long supervised field component and subsequent training and technical assistance. The curriculum teaches practical skills to assist vulnerable children, especially those HIV affected, including assessing needs, implementing case management resource linkages, counseling, family support, and ongoing service coordination. Over 500 participants have begun the para-social work program in districts throughout the country. Participants report high satisfaction with the training, and knowledge scores consistently and significantly improve throughout the training. This partnership aims to create a sustainable para-professional workforce to address gaps of most vulnerable children in Tanzania and can serve as a model to apply social work principles and techniques in settings where professional and structural resources are highly limited.

Case management for casualties of war

Purpose: To describe how case management can improve the transition between services for returning servicemen injured in war zones who often have very complex and multiple injuries. Context: Reviews a project undertaken for the Ministry of Defence in the UK. Data sources: Case management across secondary and primary care—studies; Literature relating to care of casualties from war zones; Statistical evidence on casualty numbers and type of injuries. Case description: This presentation will focus on the care of injured personnel evacuated back to the UK. Case management is to be implemented to improve the patient care pathway and make the transition between war zone, hospital and primary care fully integrated. (Preliminary) conclusions/Discussion: Care is often not co-ordinated, systems inadequate and patients returning as operational casualties have particular needs in terms of health care delivery which can be overlooked, particularly in relation to mental health needs. Case management provides a structured and co-ordinated pathway between the different services to enable continuity, a smooth transition and improve patient outcomes. However, implementation of case management will present many challenges in this environment as the case managers works with the service personnel within an NHS model of health care delivery. Within the NHS alone, integration is difficult as case managers strive to manage organisational differences between health and social care. When you add on the complexity of service personnel who have been injured whilst in a war zone, cross boundary working becomes even more difficult to manage effectively. Case management has the potential to be the one link that brings services together in a fully integrated way.

Case management for long-term conditions: implementation and processes

ABSTRACTThis paper presents a structured literature review that focused on comprehensive case management by nurses for adults with long-term conditions living in the community. The emphases of the review are the implementation of case-management approaches, including its roles, core tasks and components, and the coverage and quality of the reported implementation data. Twenty-nine studies were included: the majority were concerned with case management for frail older people, and others focused on people with multiple chronic diseases, high-cost patients, or those at high risk of hospital admissions. All the studies reported that case managers undertook the core tasks of assessment, care planning and the implementation of the care plan, but there was more variation in who carried out case finding, monitoring, review and case closure. Few studies provided adequate implementation information. On the basis of the reviewed evidence, three issues were identified as key to the coherent and sustainable implementation of case management for people with long-term conditions: fidelity to the core elements of case management; size of caseload; and case-management practice, incorporating matters relating to the continuity of care, the intensity and breadth of involvement, and control over resources. It is recommended that future evaluations of case-management interventions include a comprehensive process component or, at the very least, that interventions should be more fully described.

A Path Analysis of the Case Management Implementation Factors with Client Satisfaction and Quality of Life among the Mentally Ill Persons in the Community

A Path Analysis of the Case Management Implementation Factors with Client Satisfaction and Quality of Life among the Mentally Ill Persons in the Community

Doctors’ assistants’ views of case management to improve chronic heart failure care in general practice: a qualitative study

This paper is a report of a study to explore the views, concerns and experiences of doctors' assistants of case management for patients with chronic heart failure, while experiencing the new role of being a case manager within the Heidelberg Integrated Case Management trial. Case management is being investigated as part of a randomised controlled trial aiming to improve care for patients with chronic systolic heart failure. In a complex, multifaceted intervention, trained doctors' assistants (equivalent to a nursing role) adopted new tasks using standardised case management involving telephone monitoring, home visits and diagnostic screening. In April 2007, 3 months after implementation of the intervention programme, 27 doctors' assistants participated in four focus group interviews discussing their views on, and experiences of, case management. Thematic analysis of the data was undertaken. Participants believed that the most positive factors in case management were about interaction with patients, including opportunities for identifying disease and psychosocial problems. However, barriers included lack of time allocated to perform case management in addition to their normal role and poor cooperation within the practice team. According to the doctors' assistants, the routine implementation of case management was acceptable, feasible and effective in improving the management of patients with chronic systolic heart failure. Case management enhanced the role of doctors' assistants, leading to increased awareness of the perspective of patients with chronic disease. In the wider international primary care practice nursing context, the orchestrated delegation of tasks using specific case management may be a promising strategy for improving the quality of care of chronically ill patients and enabling patient self-management.

Why implementation processes vary across the 5A's of the Smoking Cessation Guideline: Administrators' perspectives

Unrelated to any research, 18 maternal and child health case management agencies adopted a smoking cessation program that included the ask, advise, assess, assist, and arrange components of the 2000 U.S. Public Health Service Smoking Cessation Guideline. To better understand what influences program implementation in practice, a study was conducted 18 months later at 16 (89%) of the agencies. Open-ended interviews with key administrative informants examined implementation processes (i.e., how each program component had been implemented at the organization level) and the administrators' rationales for such implementation. A separate structured telephone survey of the agency case managers (N = 63) assessed their implementation of each program component with smokers. Results showed that all agencies implemented the ask and advise components. Implementation of these components was well supported by the policies, contractual requirements, and operational tools that guided and coordinated all case management activities. No agency implemented the initially adopted program or any other structured approach to implementing the assess, assist, and arrange components. Administrative explanations indicated that these components (a) were not addressed by, and could not be easily incorporated into, the above existing policies and operational tools and (b) were perceived to be in the realm of case manager responsibilities and professional decisions, not requiring administrative attention. Several administrators also cited time constraints, other pressing case management issues, or lack of resources as additional barriers. Based on the findings, recommendations for systemic program support strategies are offered that could improve case management implementation of smoking cessation interventions beyond basic advice to quit.