Mixed Methods Multiple Case Study Research Articles

Opening access to privilege: the enactment of the IB in public schools in Costa Rica and Peru

ABSTRACT The influence of the International Baccalaureate (IB) has grown impressively on a global scale. In Latin America, the IB has been mainly introduced in private schools that cater for the most affluent sectors of society and, consequently, has been mostly interpreted as contributing to processes of social reproduction and the widening of inequalities However, since the mid-2000s the IB has been promoted in state schools in countries such as Ecuador, Peru, Costa Rica and in the City of Buenos Aires in Argentina. This paper analyses the enactment of the IBDP in public schools in Costa Rica and Peru drawing on a mixed methods multiple case study. It shows how, in countries with significant socioeconomic disparities, the possibility of offering the IBDP to students at public schools was mostly justified as a matter of equity, understood as opening access to an educational programme that was only available to the most privileged sectors of society. By problematising the notions of privilege and eliteness, we discuss the complex relations between inequalities and educational opportunities and question the extent to which these programmes are affecting social structures in Costa Rica and Peru.

The Health Impact of Social Community Enterprises in Vulnerable Neighborhoods: Protocol for a Mixed Methods Study.

BackgroundThis 4-year research project focuses on 6 social community enterprises (SCEs) that operate in 5 neighborhoods in a Dutch city. Residents of these neighborhoods face problems such as poor average levels of physical and mental health, high unemployment rates, and weak social cohesion. SCEs offer residents social, cultural, and work-related activities and are therefore believed to help these persons develop themselves and strengthen the social ties in the community. Because of a lack of empirical evidence; however, it is unclear whether and how SCEs benefit the health and well-being of participants.ObjectiveThis paper outlines a protocol for an evaluation study on the impact of SCEs, aiming to determine (1) to what extent SCEs affect health and well-being of participating residents, (2) what underlying processes and mechanisms can explain such impact, and (3) what assets are available to SCEs and how they can successfully mobilize these assets.MethodsA mixed methods multiple-case study design including repeated measurements will be conducted. Six SCEs form the cases. An integrated model of SCE health intervention will be used as the theoretical basis. First, the impact of SCEs is measured on the individual and community level, using questionnaires and in-depth interviews conducted with participants. Second, the research focuses on the underlying processes and mechanisms and the organizational and sociopolitical factors that influence the success or failure of these enterprises in affecting the health and well-being of residents. At this organizational level, in-depth interviews are completed with SCE initiators and stakeholders, such as municipal district managers. Finally, structurally documented observations are made on the organizational and sociopolitical context of the SCEs.ResultsThis research project received funding from the Netherlands Organization for Health Research and Development in 2018. Data collection takes place from 2018 until 2022. Data analysis starts after the last round of data collection in 2022 and finalizes in 2024. Expected results will be published in 2023 and 2024.ConclusionsDespite the societal relevance of SCEs, little empirical research has been performed on their functioning and impact. This research applies a variety of methods and includes the perspectives of multiple stakeholders aiming to generate new empirical evidence. The results will enable us to describe how SCE activities influence intermediate and long-term health outcomes and how the organizational and sociopolitical context of SCEs may shape opportunities or barriers for health promotion. As the number of these initiatives in the Netherlands is increasing rapidly, this research can benefit many SCEs attempting to become more effective and increase their impact. The findings of this research will be shared directly with relevant stakeholders through local and national meetings and annual reports and disseminated among other researchers through scientific publications.International Registered Report Identifier (IRRID)DERR1-10.2196/37966

Education leads to increased adherence to the ‘Australian Competency Standards for Occupational Therapy Driver Assessors’

Background Occupational therapy competency standards provide an evidence-base to inform clinical best practice, however it is not known whether education about competency standards will increase occupational therapists’ adherence to their use. Aims/objectives To investigate if education about the ‘Australian Competency Standards for Occupational Therapy Driver Assessors’ leads to increased adherence to the competency standards in the clinical practice of occupational therapy driver assessors. Materials and methods A mixed methods multiple case study design was used to evaluate 5 occupational therapy driver assessors’ adherence to the competency standards. An audit of 25 client files and interviews were conducted to evaluate practice against the competency standards prior to an education session, followed by an audit of a further 25 files, interview and feedback after education. Results Qualitative and quantitative analyses suggest that education about the ‘Australian Competency Standards for Occupational Therapy Driver Assessors’ was associated with increased adherence to the competency standards in clinical practice. The results also support the use of competency standards in clinical practice. Conclusions and significance Competency standards can be used to inform and guide clinical practice, and individualised education and feedback of practice against the competency standards can increase occupational therapists’ adherence to these standards.

Organizational Readiness for Patient-Facing Mobile Teledermatology to Care for Established Veteran Patients in the United States.

Purpose: To improve patient access to skin care, the Department of Veterans Affairs (VA) developed a patient-facing asynchronous mobile teledermatology application (app), which allows patients to follow up remotely with dermatologists. To understand how the app would be received in VA, we examined Organizational Readiness for Change (ORC), an important prelude to effective implementation, which includes the shared resolve and collective ability of organizational members to implement a change. Methods: We used a mixed-methods multiple case study approach to assess ORC at three VA facilities. Data derived from a site process call, surveys, and semistructured telephone interviews of VA staff, field notes, and administrative data. Results: Participants at all three facilities supported the intervention and recognized the value of using the app to increase patients' access to dermatologists, but expressed concerns largely related to disruption of the pre-existing clinical workflow. Participants at the facility most actively using the app had the highest overall ORC score and reported the most facilitators. Facility leadership support when guided by a clinical champion minimized barriers by recognizing the complexities of health care provision at specialty clinics. Discussion: While provider buy-in remained a barrier, leadership, guided by the clinical champion, played a critical role instituting implementation strategies. The strong association between the ORC survey score and the presence of facilitators and barriers suggests that the ORC survey may be a rapid, convenient, and effective tool for health care systems to identify favorable sites for wider implementation of mobile telehealth care. Clinical Trials Identifier: NCT03241589.

Clinical variation in the organization of clinical pathways in esophagogastric cancer, a mixed method multiple case study

BackgroundAmong esophagogastric cancer patients, the probability of having undergone treatment with curative intent has been shown to vary, depending on the hospital of diagnosis. However, little is known about the factors that contribute to this variation. In this study, we sought to understand the organization of clinical pathways and their association with variation in practice.MethodsA mixed-method study using quantitative and qualitative data was conducted. Quantitative data were obtained from the Netherlands Cancer Registry (e.g., outpatient clinic consultations and diagnostic procedures). For qualitative data, thematic content analysis was performed using semi-structured interviews (n = 30), observations of outpatient clinic consultations (n = 26), and multidisciplinary team meetings (MDTM, n = 16) in eight hospitals, to assess clinicians’ perspectives regarding the clinical pathways.ResultsQuantitative analyses showed that patients more often underwent surgical consultation prior to the MDTM in hospitals associated with a high probability of receiving treatment with curative intent, but more often consulted with a geriatrician in hospitals associated with a low probability of such treatment. The organization of clinical pathways was analyzed quantitatively at three levels: regional, local, and patient levels. At a regional level, hospitals differed in terms of the number of patients discussed during the MDTM. At the local level, the revision of radiological images and restaging after neoadjuvant treatment varied. At the patient level, some hospitals routinely conduct fitness tests, whereas others estimated the patient’s physical fitness during an outpatient clinic consultation. Few clinicians performed a standard geriatric consultation in older patients to assess their mental fitness and frailty.ConclusionSurgical consultation prior to MDTM was more often conducted in hospitals associated with a high probability of receiving treatment with curative intent, whereas a geriatrician was consulted more often in hospitals associated with a low probability of receiving such treatment.

Better understanding care transitions of adults with complex health and social care needs: a study protocol

BackgroundAdults with chronic conditions who also suffer from mental health comorbidities and/or social vulnerability require services from many providers across different sectors. They may have complex health and social care needs and experience poorer health indicators and high mortality rates while generating considerable costs to the health and social services system. In response, the literature has stressed the need for a collaborative approach amongst providers to facilitate the care transition process. A better understanding of care transitions is the next step towards the improvement of integrated care models. The aim of the study is to better understand care transitions of adults with complex health and social care needs across community, primary care, and hospital settings, combining the experiences of patients and their families, providers, and health managers.Methods/designWe will conduct a two-phase mixed methods multiple case study (quantitative and qualitative). We will work with six cases in three Canadian provinces, each case being the actual care transitions across community, primary care, and hospital settings. Adult patients with complex needs will be identified by having visited the emergency department at least three times over the previous 12 months. To ensure they have complex needs, they will be invited to complete INTERMED Self-Assessment and invited to enroll if positive. For the quantitative phase, data will be obtained through questionnaires and multi-level regression analyses will be conducted. For the qualitative phase, semi-structured interviews and focus groups will be conducted with patients, family members, care providers, and managers, and thematic analysis will be performed. Quantitative and qualitative results will be compared and then merged.DiscussionThis study is one of the first to examine care transitions of adults with complex needs by adopting a comprehensive vision of care transitions and bringing together the experiences of patients and family members, providers, and health managers. By using an integrated knowledge translation approach with key knowledge users, the study’s findings have the potential to inform the optimization of integrated care, to positively impact the health of adults with complex needs, and reduce the economic burden to the health and social care systems.

Objective and subjective performance indicators of clutch performance in basketball: A mixed-methods multiple case study

Clutch performance refers to improved or successful performance under pressure. Whether such performances should be assessed using objective indicators (e.g., performance statistics) or subjective indicators (e.g., athletes’ perceived performance) remains an important unresolved issue within the field. The aim of this study was to examine the types of performance indicators that basketballers use to identify clutch performance. A mixed-methods multiple case study design was adopted involving four semi-elite basketballers (3 male, 1 female). Four sources of data were collected: (1) performance statistics; (2) a screening questionnaire measuring pressure and perceived performance; (3) observations; and (4) event-focused interviews. As two participants reported on two different performances, a total of six cases were included. Within-case analysis was conducted to become familiar with each case, followed by an integrated cross-case analysis. Results suggested that whilst objective indicators are important for identifying clutch performance, these were often viewed through a subjective lens. Further, subjective indicators such as perceived effort and control appear similarly important in assessing clutch performance. Lastly, it was reported that clutch performances do not always require winning, but may rather be about a sense of contributing to the team performance. Overall, these findings suggest that operationalizations of clutch performance should consider athletes’ subjective interpretations, and not rely solely on objective indicators. Lay summary: An important step in facilitating performance under pressure is understanding how to measure such performances. This study suggests that athletes’ perceptions of their performance under pressure are important to consider, and may not align with traditional objective performance indicators, such as performance statistics. Implications for practice When examining performance under pressure, practitioners should consider athletes’ own interpretations of objective performance indicators Practitioners may also consider examining subjective indicators of performance, such as perceived effort or control when measuring performances under pressure Encouraging athletes to contribute toward the team performance, rather than focusing on the outcome, may facilitate assessments of clutch performance.

Exploring Changes in Home Visitors' Perspectives in the Context of a Professional Development Activity.

Research-based professional development opportunities for early childhood home visitors are valuable to the Early Head Start-Home-Based Option (EHS-HBO) and to the home visiting field broadly to strengthen effective practice. We explored EHS-HBO home visitors’ (N = 5) perspectives on effective practice through a professional development activity that included viewing videos of their own practice, analyzing the video and assessment data of their practice and parent–child interactions, and reflection. A convergent mixed methods multiple-case study was used. A variety of skills were noted within each case as indicators of effective practice, suggesting that a plethora of complex skills are needed to work with families. Across-case analytic strategies were used to compare subthemes, codes, and substantial statements across cases to generate themes. Two major themes emerged from our data analysis across cases: practicing self-reflective consciousness and building foundations for parent–child interactions. The findings have implications for professional development activities.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10643-021-01249-3.

Dropping in, Helping Out: Social Support and Weak Ties on Traditional Medicine Social Networking Sites

This exploratory study analyses the network mechanisms with which Vietnamese traditional medical knowledge propagates on Facebook and explores patterns of social support provided by weak ties on these sites. The study employs a mixed-method multiple case study approach. Social network analysis is conducted on a sample of 6,293 original posts and 23,333 associated comments on two Vietnamese traditional medicine sites on Facebook, over three years. Content analysis is performed on a subsample of 2,570 comments made by nodes with a degree of one, together with 1,543 associated original posts. Findings indicate that weak ties are much more prevalent among discourse communities where communicative exchanges lie outside existing regulatory frameworks concerning traditional medicine. An overwhelming majority of these weak ties provide mostly informational support, while other forms of support such as emotional, esteem, network, or tangible are much less prevalent. This study suggests that weak ties play an important role in providing action-facilitating support, particularly within discourse networks that are outside of the current Vietnamese regulatory frameworks on traditional medicine. Community detection techniques performed on the dataset also show that discourse communities within networks containing more weak ties are harder to break than those containing fewer weak ties.

A mixed methods multiple case study to evaluate the implementation of a care pathway for colorectal cancer surgery using extended normalization process theory

BackgroundSpecific factors that facilitate or prevent the implementation of enhanced recovery protocols for colorectal cancer surgery have been described in previous qualitative studies. This study aims to perform a concurrent qualitative and quantitative evaluation of factors associated with successful implementation of a care pathway (CP) for patients undergoing surgery for colorectal cancer.MethodsThis comparative mixed methods multiple case study was based on a sample of 10 hospitals in 4 European countries that implemented a specific CP and performed pre- and post-implementation measurements. In-depth post-implementation interviews were conducted with healthcare professionals who were directly involved. Primary outcomes included protocol adherence and improvement rate. Secondary outcomes included length of stay (LOS) and self-rated protocol adherence. The hospitals were ranked based on these quantitative findings, and those with the highest and lowest scores were included in this study. Qualitative data were summarized on a per-case basis using extended Normalization Process Theory (eNPT) as theoretical framework. The data were then combined and analyzed using joint display methodology.ResultsData from 381 patients and 30 healthcare professionals were included. Mean protocol adherence rate increased from 56 to 62% and mean LOS decreased by 2.1 days. Both measures varied greatly between hospitals. The two highest-ranking hospitals and the three lowest-ranking hospitals were included as cases. Factors which could explain the differences in pre- and post-implementation performance included the degree to which the CP was integrated into daily practice, the level of experience and support for CP methodology provided to the improvement team, the intrinsic motivation of the team, shared goals and the degree of management support, alignment of CP development and hospital strategy, and participation of relevant disciplines, most notably, physicians.ConclusionsOverall improvement was achieved but was highly variable among the 5 hospitals evaluated. Specific factors involved in the implementation process that may be contributing to these differences were conceptualized using eNPT. Multidisciplinary teams intending to implement a CP should invest in shared goals and teamwork and focus on integration of the CP into daily processes. Support from hospital management directed specifically at quality improvement including audit may likewise facilitate the implementation process.Trial registrationNCT02965794.US National Library of Medicine, ClinicalTrials.gov. Registered 4 August 2014.

Human Ecological Systems Shaping College Readiness of Filipino K-12 Graduates: A Mixed-Method Multiple Case Analysis

How ready are the K-12 graduates in the Philippines? What environmental conditions shape their college readiness? How do these conditions help to prepare them to transition from basic to tertiary education seamlessly and effectively? This study answers these questions by utilizing a mixed-method multiple case study design framed within the Human Ecological Systems Model. The 7,238 respondents and 28 study participants were first-year students enrolled in one state university in northern Philippines. Results revealed that the Filipino K-12 graduates demonstrated less preparedness for college education. The variables under human ecological systems influencing their college readiness include sex, gender, birth order (individual system), parents’ monthly income (microsystem), type of senior high school (SHS) graduated and track taken in SHS (mesosystem), parents’ location of employment (exosystem); and ethnicity and parents’ educational attainment (macrosystem). Such findings prove that college readiness among K-12 graduates is not solely dependent on their cognitive abilities but is a confluence of environmental conditions from the individual to macrosystems. Thus, the human ecological system serves as a functional frame in understanding factors shaping the college readiness of K-12 graduates and it is recommended that the conditions under each system must be considered as valuable inputs for basic education in preparing K-12 students for college life.

Volunteer Motivation and Retention of Older Peer Walk Leaders: A 4-Month Long Investigation.

Peer volunteers offer a promising avenue for promoting physical activity in older adults. However, recruiting and retaining such volunteers are challenging. We aimed to examine longitudinally factors that determine whether older volunteer walk leaders will persist in their role. We recruited older adults volunteering as walk leaders, from retirement villages in Perth, at the start of a 16-week walking intervention. Using a mixed-methods multiple case study design, informed by self-determination theory, we examined the motivational processes of three profiles: Dropouts, Completers, and Extenders. One male and 10 female (medianAge = 75 years, age range: 66-83 years) peer walk leaders were interviewed twice over 4 months, and data were analyzed using thematic analysis. Questionnaires provided information on volunteer characteristics, leadership confidence, and volunteer motivation. Self-orientated goals, obligation and guilt, emotional exhaustion, lack of psychological need satisfaction, and perceived lack of support were barriers to volunteer persistence. Social confidence and relatedness satisfaction motivated volunteers to persist until program completion (Completers). Altruistic goals, using sustainable helping strategies, psychological need satisfaction, optimism, and enjoyment were important for continuing the role after the program (Extenders). Results describe how differences in volunteer motives, personal characteristics, and training may affect motivational processes that determine persistence as an older peer walk leader. We provide suggestions on selecting, training, and supporting older volunteer walk leaders to facilitate their retention.

Improving quality in clinical placement studies in nursing homes (QUALinCLINstud): the study protocol of a participatory mixed-methods multiple case study design

IntroductionImproved quality in clinical supervision and assessment of student nurses in nursing home clinical placements is vitally important to effective recruitment and preparation for this healthcare sector. Knowledge regarding supervision...

Exploring the factors influencing the use of electrically assisted bikes (e-bikes) by stroke survivors: a mixed methods multiple case study

Purpose E-bikes have the potential to overcome some of the barriers that stroke survivors face with regards to physical activity. This study aims to explore the factors that affect e-bike usage by stroke survivors. Methods A mixed methods multiple case studies design, using semi-structured interviews and GPS data. Subject to GP approval, participants loaned an e-bike or e-trike for up to three months. Interviews were undertaken pre and post intervention. The COM-B behaviour change model acted as a framework for analysis. GPS data relating to journey duration and distance travelled was collected fortnightly. Results Six participants were recruited; only three loaned an e-bike/e-trike (with adaptations as required). Storage, being unable to get GP approval, and safety were withdrawal reasons. Level of impairment was a factor influencing the type of e-bike used, level of support required and the motivation of the participants. Conclusion Stroke survivors can use e-bikes although barriers exist. Electrical assistance was a positive factor in enabling some of the participants to cycle outdoors. Due to the small sample size and the number of participants who were able to loan an e-bike, further research is required to determine whether e-bikes are a feasible and effective intervention to increase physical activity for stroke survivors. IMPLICATIONS FOR REHABILITATION The assistance provided by the e-bike/e-trike could provide stroke survivors the opportunity to cycle outdoors. E-bikes/e-trikes could facilitate participation of activities of everyday living such as shopping, hobbies and increase levels of physical activity. Rehabilitation could focus on physical impairment, its effects on self-confidence, and knowledge surrounding the e-bike to overcome barriers to cycling. Social support, the belief that e-bike was an enjoyable mode of physical activity that was good for their health were reported by the participants as important factors for using the e-bike/e-trike.

411 Implementation of a consultative teledermatology mobile application in Veterans Affairs

To facilitate consultative asynchronous teledermatology, Veterans Affairs (VA) introduced a mobile application at 3 sites. We evaluated the initial implementation process using a mixed methods multiple case study approach to assess readiness to implement the intervention in each facility, as well as the facilitators, barriers and contextual factors. Data sources included: 1) Interviews and an organizational readiness to change (ORC) survey conducted at one site; 2) Interviews at all sites with groups of physicians, nurses, administrators, and information technology (IT) professionals; and 3) Implementation documentation from the operational partner. Initial stakeholder support at all sites, corroborated by survey data, indicated a readiness for change. Support from both leadership and staff was a positive organizational characteristic. Each site had telehealth meetings to foster communication but only one was active with members from all departments with roles in telehealth. Each site had staff to ensure that imagers—primary users of the new app—were trained, but one had an additional staff member devoted to education of new telehealth projects; access to one-on-one guidance facilitated greater understanding of the process. At all 3 sites, staff experienced technical difficulties that negatively affected adoption, particularly due to the inability to address these problems quickly. Additional organizational characteristics that adversely affected ORC included users’ perceptions of additional workload and suboptimal IT infrastructure/support. These findings may be useful for informing rollout of future mobile telehealth endeavors in VA and other health care organizations.

Determinants of technology use for a mobile health intervention across public health facilities in rural India: Protocol for implementation research

This paper presents a research protocol for implementation research (IR) to investigate contextual factors influencing the implementation of ASMAN mobile health intervention and their association with maternal, newborn, and child health outcomes. The IR will cover roughly 16-20 public health facilities across the states of Rajasthan and Madhya Pradesh in India. These facilities will be a sub-sample of 49 facilities covered separately under the outcome evaluation. The study employs a longitudinal mixed-methods multiple case study design with sequential data collection using constructs under the Consolidated Framework for Implementation Research (CFIR) across two phases. The first phase will be exploratory and use qualitative inquiry to contextualize the CFIR constructs. The second phase will employ a mixed-methods explanatory design with both validated and contextualized CFIR constructs and standard quantitative measures collected through outcome evaluation. Findings from this study will provide insights into factors that facilitate or impede the implementation of mobile health interventions and their association with MNCH outcomes in public health facilities in India.

Making Future-Ready Students with Design and the Internet of Things

INTRODUCTION: IoT will transform our future in unimaginable ways. The necessity for young people to understand and design with IoT seems unequivocal but there is currently limited integration in K-12 education. OBJECTIVES: To investigate these gaps in research and practice, this study aimed to explore the design processes and understandings of IoT that emerge when youth design an IoT passion project within a constructionist context. METHODS: A mixed methods multiple case study design was employed, analyzing questionnaires, interviews, recordings, and participant artifacts. RESULTS: Factors contributing to a successful design included guided inquiry, detailed plans, access to support, and perseverance. Participants also experienced gains in IoT skills and knowledge. CONCLUSION: Design and making with IoT through passion-based, guided inquiry appeared to facilitate the development of valuable knowledge and skills. Further research is needed to explore implementations in formal education.

The effects of customer-centricity in hospitality

Hospitality is a field in which guests’ specific needs and wants should always be given serious consideration by hoteliers. Putting the guest at the centre of all business efforts contributes to generating customer value and enhancing a firm’s competitiveness. Being customer-centric is paramount for hospitality establishments to create and sustain superior customer value. However, there is scant evidence in hospitality marketing literature of a clear understanding of the customer-centricity concept or of the possible effects of its implementation. Using a mixed-methods multiple case study approach, this research studies two different properties that, to some extent, are already engaged in customer-centricity practices through the use of advanced Customer Relationship Manager software. Results clearly show an increase in customer ratings, leading to possible profit implications; a cultural shift within the organizations studied connected with the customer-centricity phenomenon has also been reported.

Attributes of High-Performing Small Practices in a Guideline Implementation: A Multiple-Case Study.

ObjectiveHealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation.MethodsA mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices.ResultsOur first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager.ConclusionsThese attributes may be important determinants of high performance, indicating not only a small practice’s capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.

Optimizing Licensed Practical Nurses in Home Care: Their Role, Scope and Opportunities.

This research examined the role and scope of licensed practical nurses (LPNs) in home care (HC) and case management. Case management is relatively new to LPNs in Alberta having been added to their list of competencies in 2015. The extent to which LPNs are performing functions and the circumstances or criteria that shape their reported case management functions and role are not clear. Our research questions were: a) What roles do LPNs play within HC and case management? and b) What roles could LPNs play within HC and case management given their scope of practice to achieve optimal client outcomes and system efficiencies? We used a mixed methods multiple case study design to engage LPNs in case management practice, their managers and HC leaders from rural, urban and suburban HC offices. Approaches for data collection included semi-structured interviews, participant observation, focus groups, document review and survey.