Case managers for older persons with multi-morbidity and their everyday work – a focused ethnography

Abstract

BackgroundModern-day health systems are complex, making it difficult to assure continuity of care for older persons with multi-morbidity. One way of intervening in a health system that is leading to fragmented care is by utilising Case Management (CM). CM aims to improve co-ordination of healthcare and social services. To better understand and advance the development of CM, there is a need for additional research that provides rich descriptions of CM in practice. This knowledge is important as there could be unknown mechanisms, contextual or interpersonal, that contribute to the success or failure of a CM intervention. Furthermore, the CM intervention in this study is conducted in the context of the Swedish health system, which prior to this intervention was unfamiliar with this kind of coordinative service. The aim of this study was to explore the everyday work undertaken by case managers within a CM intervention, with a focus on their experiences.MethodsThe study design was qualitative and inductive, utilising a focused ethnographic approach. Data collection consisted of participant observations with field notes as well as a group interview and individual interviews with nine case managers, conducted in 2012/2013. The interviews were recorded, transcribed verbatim and subjected to thematic analysis.ResultsAn overarching theme emerged from the data: Challenging current professional identity, with three sub-themes. The sub-themes were 1) Adjusting to familiar work in an unfamiliar role; 2) Striving to improve the health system through a new role; 3) Trust is vital to advocacy.ConclusionsFindings from this study shed some light on the complexity of CM for older persons with multi-morbidity, as seen from the perspective of case managers. The findings illustrate how their everyday work as case managers represents a challenge to their current professional identity. These findings could help to understand and promote the development of CM models aimed at a population of older persons with complex health needs.

The Encounters and Challenges of Ethnography as a Methodology in Health Research

“…This might be indicative of the fact that the value of fieldwork is not acknowledged in existing health studies (Bright et al, 2012;Braaf, Manias, & Riley, 2014;Carroll, Iedema, & Kerridge, 2008;Gustafsson, Kristensson, Holst, Willman, & Bohman, 2013). From the studies in Table 2, it becomes apparent that health researchers use the most convenient form of ethnography to explore a particular phenomenon.…”

“…Researchers should be explicit about their ontological and epistemological stance to better understand the perspective from which they explore and find answers for their research question. Many authors claim that their study is a ''focused ethnography,'' even though methodological background information commonly focuses on ''qualitative methods'' or ''ethnography,'' in a general manner (Gustafsson et al, 2013;Magilvy, McMahon, Bachman, Roark, & Evenson, 1987;Pino et al, 2013). In conclusion, we recommend that health researchers conducting ethnography be more explicit in detailing their ''tradition and paradigm of inquiry '' (O'Byrne, 2007'' (O'Byrne, , p. 1389.…”

“…More recently, ethnographers have attended more closely to exploring specific cultures within a border range of cultures or intracultural diversity (examination subcultures with culture; Fetterman, 2010). Similarly, existing ethnographic health research listed in Table 2 (Braaf et al, 2014;Bright et al, 2012;Carroll et al, 2008;Gustafsson et al, 2013) does not focus on culture from a border perspective. For example, in health research, the focus is often on single issue such as understanding experiences of patients with chronic pain (White & Seibold, 2008) or exploration of a deaf identity (McIlroy & Storbeck, 2011) and exploring issues of case managers for older persons with multimorbidity (Gustafsson et al, 2013).…”

Managing the Needs of Older Patients with Multimorbidity—A Systematic Review of the Challenges Faced by the Healthcare Services

“…Social contacts, physical activity and optimism may improve mental health, while social isolation, ageing and chronic pain may cause it to deteriorate [6]. Gustafsson et al [7] found one theme; Challenging current professional identity based on three sub-themes; 1) Adjusting to familiar work in an unfamiliar role; 2) Striving to improve the health system through a new role; 3) Trust is vital for advocacy [7]. A cross-sectional study by Noël et al [8] compared the self-management learning needs and willingness to encounter non-physician care providers of patients with multimorbidity and those with a single chronic illness.…”

“…The participants experienced uncertainty that increased with their experience of side effects, leading to concern that the medication might be harmful. Four other qualitative studies investigated perceptions and experiences of older patients with multimorbidity, mainly from the perspective of physicians [4]- [7]. Bayliss et al [4] revealed that the patients wanted easy access to healthcare, individualized care plans, support from one care coordinator and continuity of relationships with healthcare professionals who had a caring attitude, listened to them and appreciated that their needs were unique and fluctuating.…”