Case management for older persons with multi-morbidity. Experiences of an intervention from the perspectives of older persons, family members, case managers and health and social care staff members
Sammanfattning: Complex health systems make it difficult to ensure a continuity of care for older persons with multi-morbidity, and risk fragmented care. Fragmented care could affect the quality and safety of the care provided. Case management could provide an approach to counteract this unfavourable situation. Case management is practised by case managers and aims to improve the coordination of healthcare and social services. To better understand and to advance the progress of case management, there is a need for knowledge that provides rich descriptions of case management in practice. This knowledge must come from different perspectives important for the intervention. Thus, the overall aim of this thesis was to explore the experiences of a case management intervention aimed at older persons with multi-morbidity, from the perspectives of case managers, older persons, family members and health and social care staff members.The work of this thesis is based on an ethnographic approach and explores case management from multiple perspectives. For Study I, the sample consisted of case managers (n=9). Data were collected by a group interview, individual interviews and participant observations. Data analysis was informal and formal, and comprised a thematic analysis of the interview material. For Study II, the sample consisted of family members of older persons with multi-morbidity (n=16). Data were collected by individual interviews and analysed using interpretive phenomenology. For Study III, the sample consisted of older persons (75+) with multi-morbidity (n=13). Individual interviews and participant observations were part of the data collection. Data analysis was influenced by Roper and Shapira’s framework for ethnographic analysis. For Study IV the sample consisted of health and social care staff members (n=10). Individual interviews were conducted and subsequently analysed using thematic analysis. The findings from all studies (I-IV) illustrated different perspectives of a case management intervention, conducted by case managers. In Study I, the case managers’ experiences of their everyday work could be interpreted as challenging current professional identity. Study II showed that the family members’ experiences could be interpreted as helps to fulfil my unmet needs. In Study III, the older persons’ experiences were interpreted into four themes which were someone providing me with a trusting relationship; someone assisting me; someone who is on my side; and someone I do not need at present. In Study IV, health and social care staff members’ experiences were interpreted into the following three themes: could bridge gaps in an insufficient health system; emerging improvements call for engagement; and an intervention in the mist with vague goals and elements.In summary, the findings indicate that establishing trusting relationships was important and this trust enabled the case managers to conduct their everyday work. Consequently, case management interventions need to put emphasis on building trust between the case managers and the participants. To facilitate trusting relationships it is envisaged that it could be of help if the case managers are in a neutral position, act as an individual contact, and have regular contact with the participants. Continuity of the case managers’ services seems to be important for developing trusting relationships. The case managers’ everyday work put forth challenges of trying to make sense of their role as case manager. Thus, when intervening with case management it is important to present a clear description of the case manager’s professional responsibility to all involved. Using working groups as an intermediate for conducting improvement work at an organisational level seems to show promises. But, engagement amongst its representatives is vital for it to be successful. Expectations regarding the working groups and the intervention needs be made clear and discussed throughout the course of the intervention. Thus, a vital part of the preparation for the case management intervention should be to explicitly set the expectations for all involved parties.
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