Bamford Claire, Poole Marie, Brittain Katie, Chew-Graham Carolyn, Fox Chris, Iliffe Steve, Manthorpe Jill, Robinson Louise
Institute of Health and Society, Newcastle University, Baddiley Clark Building, Richardson Road, Newcastle NE2 4AX, UK.
BMC Health Serv Res. 2014 Nov 8;14:549. doi: 10.1186/s12913-014-0549-6.
Case management has been suggested as a way of improving the quality and cost-effectiveness of support for people with dementia. In this study we adapted and implemented a successful United States' model of case management in primary care in England. The results are reported elsewhere, but a key finding was that little case management took place. This paper reports the findings of the process evaluation which used Normalization Process Theory to understand the barriers to implementation.
Ethnographic methods were used to explore the views and experiences of case management. Interviews with 49 stakeholders (patients, carers, case managers, health and social care professionals) were supplemented with observation of case managers during meetings and initial assessments with patients. Transcripts and field notes were analysed initially using the constant comparative approach and emerging themes were then mapped onto the framework of Normalization Process Theory.
The primary focus during implementation was on the case managers as isolated individuals, with little attention being paid to the social or organizational context within which they worked. Barriers relating to each of the four main constructs of Normalization Process Theory were identified, with a lack of clarity over the scope and boundaries of the intervention (coherence); variable investment in the intervention (cognitive participation); a lack of resources, skills and training to deliver case management (collective action); and limited reflection and feedback on the case manager role (reflexive monitoring).
Despite the intuitive appeal of case management to all stakeholders, there were multiple barriers to implementation in primary care in England including: difficulties in embedding case managers within existing well-established community networks; the challenges of protecting time for case management; and case managers' inability to identify, and act on, emerging patient and carer needs (an essential, but previously unrecognised, training need). In the light of these barriers it is unclear whether primary care is the most appropriate setting for case management in England. The process evaluation highlights key aspects of implementation and training to be addressed in future studies of case management for dementia.
有人提出病例管理是提高痴呆症患者支持服务质量和成本效益的一种方式。在本研究中，我们对美国一种成功的病例管理模式进行了调整，并在英国的初级保健中实施。研究结果已在其他地方报告，但一个关键发现是病例管理开展得很少。本文报告了过程评估的结果，该评估使用了规范化过程理论来理解实施过程中的障碍。
采用人种志方法来探究病例管理的观点和经验。对49名利益相关者（患者、护理人员、病例管理人员、卫生和社会护理专业人员）进行了访谈，并在会议期间以及对患者进行初次评估时观察病例管理人员。最初使用持续比较法对转录文本和现场记录进行分析，然后将新出现的主题映射到规范化过程理论的框架上。
实施过程中的主要关注点是作为个体的病例管理人员，而很少关注他们工作的社会或组织背景。确定了与规范化过程理论的四个主要构成要素相关的障碍，包括干预的范围和界限不明确（连贯性）；对干预的投入不一（认知参与）；缺乏提供病例管理的资源、技能和培训（集体行动）；以及对病例管理人员角色的反思和反馈有限（反思性监测）。
尽管病例管理对所有利益相关者都具有直观吸引力，但在英国初级保健中实施存在多重障碍，包括：难以将病例管理人员融入现有的成熟社区网络；为病例管理争取时间的挑战；以及病例管理人员无法识别并应对患者和护理人员新出现的需求（这是一项基本但此前未被认识到的培训需求）。鉴于这些障碍，尚不清楚初级保健是否是英国病例管理最合适的环境。该过程评估突出了病例管理未来研究中需要解决的实施和培训的关键方面。
