Experiences of case managers in providing person-centered and integrated care based on the Chronic Care Model: A qualitative study on embrace.

BACKGROUND: Due to the rise in the number of older adults within the population, healthcare demands are changing drastically, all while healthcare expenditure continues to grow. Person-centered and integrated-care models are used to support the redesigning the provision of care and support. Little is known, however, about how redesigning healthcare delivery affects the professionals involved. OBJECTIVES: To explore how district nurses and social workers experience their new professional roles as case managers within Embrace, a person-centered and integrated-care service for community-living older adults. METHODS: We performed a qualitative study consisting of in-depth interviews with case managers (district nurses, n = 6; social workers, n = 5), using a topic-based interview guide. Audiotaped interviews were transcribed verbatim and analyzed using qualitative content analysis. RESULTS: The experiences of the case managers involved four major themes: 1) the changing relationship with older adults, 2) establishing the case-manager role, 3) the case manager's toolkit, and 4) the benefits of case management. Within these four themes, subthemes addressed the shift to a person-centered approach, building a relationship of trust, the process of case management, knowledge and experience, competencies of and requirements for case managers, and the differences in professional background. DISCUSSION: We found that this major change in role was experienced as a learning process, one that provided opportunities for personal and professional growth. Case managers felt that they were able to make a difference, and found their new roles satisfying and challenging, although stressful at times. Ongoing training and support were found to be a prerequisite in helping to shift the focus towards person-centered and integrated care.

Managing the Social Determinants of Health: Part II: Leveraging Assessment Toward Comprehensive Case Management.

BEHAVIORAL LEARNING OBJECTIVES: This article will: PRIMARY PRACTICE SETTINGS(S):: Applicable to health and behavioral health settings where case management is practiced. FINDINGS/CONCLUSIONS: When professional case managers use comprehensive assessments to inform their work with populations impacted by the SDH, barriers to care access can be more readily addressed (e.g., poverty, employment, housing insufficiency, health literacy, migration, and medication adherence). Initiatives, programming, and treatment plans can be advanced to provide target populations with individualized and appropriate intervention. Case management involvement can also be leveraged to coordinate and facilitate successful interprofessional team efforts (; ). IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case managers must engage clients from a wholistic lens that reflects their standards of practice and accounts for all domains of assessment: medical, cognitive and behavioral, functional, and social. Comprehensive tools to guide a robust and exhaustive screening of issues and opportunities ensure more successful outcomes.

Assessing the whole person: case managers take a holistic approach to physical and mental health.

PURPOSE/OBJECTIVE: Given the prevalence of mental health issues, particularly depressive disorders, in the U.S. population, professional case managers should increase their sensitivity to and awareness of mental illnesses, as well as their impact on physical health. Throughout the case management process, case managers frequently observe behaviors and symptoms such as those associated with depressive disorders. Case managers need to have, at a minimum, a working knowledge of mental and behavioral health issues and be familiar with basic screening tools. This will enable them to become more attuned to symptoms and behaviors that indicate that the individual should be further assessed and diagnosed by a physician. PRIMARY PRACTICE SETTING: Across the case management spectrum, including acute care, accountable care organizations, patient-centered medical homes, physician practices, clinics, occupational health clinics, workers' compensation, and other settings in which case managers work with individuals (clients who receive case management services) and their families/support systems. FINDINGS/CONCLUSIONS: With more than one quarter of the U.S. population affected by a depressive disorder, professional case managers who practice holistically bring together the mental and physical aspects of health. This is particularly important in a health care system and among payer sources that continue to divide the two. Case managers elevate their practice by demonstrating a greater understanding of the interconnectedness of mental and physical health and can positively influence the transdisciplinary care team to take a person-centered approach to address all health issues, in pursuit of the individual's health goals. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Professional case managers must increase their understanding of mental health, becoming more aware of "red flags" that may necessitate a further evaluation and assessment by a mental health professional. They should also hone their communication skills, particularly the use of motivational interviewing techniques, to encourage individuals to discuss their feelings, worries, fears, and anxiety, as well as any potential symptoms of depression, which may range from mild to severe. Without judgment or bias, the case manager, as the advocate, can provide the information, support, or other services needed to address mental health issues, to support and further the individual's health goals.