Background
Method
Design
Setting
Characteristics of different models | Linkage model | Intensive case management/joint agency model |
---|---|---|
Central point for registration of cognitively impaired persons
| New clients are referred by GP or medical specialist to the central registration point after diagnosis | New clients are referred by GP or medical specialist to the Multidisciplinary team at central registration point before or after diagnosis |
Possibility to diagnose dementia
| No, CM generally starts after diagnosis | By Multidisciplinary team |
Starting point of case management
| After diagnosis | Also possible before diagnosis; e.g. in case of MCI or suspicion of dementia. |
Delivery of services
| Independent and competitive organizations that often differ regarding case manager tasks and type of employment. | Mainly by one organization that provides uniform case manager tasks |
Multidisciplinary team
| Intramural or extramural expert team that case managers can consult. Not always operating in the same organization. Frequency of consultation varies | Elderly care physicians, neuropsychologist, neurologist, geriatrician, psychiatrist, dementia consultant all work within the same organization as case managers |
Financing
| Annual contracts with insurance companies. Funding is provided based on the “Law on Exceptional Medical Expenses” (AWBZ) as well as municipalities (WMO). | Annual contracts with insurance companies. Funding is provided based on the Law on Exceptional Medical Expenses (AWBZ) as well as municipalities (WMO). Sometimes diagnostics and treatment tasks are funded by the Health Insurance Act (Zvw) and certain case manager tasks are covered by the Diagnostic Treatment Combinations (DBC). |
Data collection
Analysis
Results
Comparing the linkage and intensive model
Intensive | Linkage | Nivel | ||
---|---|---|---|---|
Characteristics of case management
| ||||
Facilitating
| Using existing non-dementia case management models as example | + | ||
Impeding
| Disagreement about content of case manager tasks | - | - | |
Partners do not see the added value of a case manager who only mediates | - | |||
Speed of implementation depends on mentality and cultural values of the region | - | |||
Time and other operational preconditions
| ||||
Facilitating
| Sufficient time to set up an organizational structure | + | + | |
Impeding
| Professionals don't have innovation time; consensus among many collaboration partners takes time | - | ||
No clear guidelines for implementation | - | - | ||
Human and financial resources
| ||||
Facilitating
| Retraining district nurses to become case managers facilitates collaboration with the GP as they have pre-existing partnerships | + | ||
Presence of a clear initiator of the implementation | + | |||
Impeding
| Proliferation of different types of case managers created friction among providers | - | - | |
Lack of clarity about the role of the project leader (not knowing who is their superior) | - | |||
Organizational conditions
| ||||
Facilitating
| Embedding case management in Mental Health Care promotes collaboration |
+
| ||
Embedding the multidisciplinary expert team in case management organization | + | |||
Good collaboration between case managers from competitive providers provides the opportunity to learn from each other | + | + | ||
Case managers from one provider all working in the same room enhances sparring and consultation | + | |||
Presence of a Board of Representatives to guide the dementia care network. | + | + | ||
Presence of fixed stakeholders at partners in the dementia care network whom case managers can contact | + | + | ||
Impeding
| Presence of competitive providers of case management within the dementia care network | - | - | |
Different interests of the Board of Representatives; incomplete attendance during meetings; members without mandate to make decisions. | - | |||
Expert team doe not function properly; difficult to reach clinicians as members participate only a few hours per week. | - | |||
Lack of clarity about who is responsible for what aspects of implementation and collaboration | - | |||
Only incorporating dementia care partners with the strongest pre-existing relationships at the start | - |
Intensive
|
Linkage
| Nivel | |||||
---|---|---|---|---|---|---|---|
Case manager characteristics | Execution | Continuation | Execution | Continuation | |||
Micro level
|
Facilitating
| Large case manager team made it possible to consider individual competences and a differentiated offer of tasks | + | ||||
Increase in experience enabled case managers to discuss clients without the expert team | + | ||||||
Impeding
| Case manager with a dual role encounter time restraints and run a burn out risk | - | |||||
Creating additional tasks + increase of caseloads leads to higher work pressure (especially when case managers have dual-jobs). No clear agreements about who is responsible for additional tasks | - | ||||||
Individual differences + increase in case manager team makes uniform way of practice difficult | - | ||||||
Difficulty hiring case managers with the right qualifications for the job | - | ||||||
Increase in case managers means less time per case manager to discuss clients in expert team | - | ||||||
Content of case management
| |||||||
Micro level
|
Facilitating
| Protocols that allow case managers to indicate which clients have a priority for nursing home admission | + | ||||
Impeding
| Difficulty to approach expert team when imbedded in an intramural setting and/or when crossing over to a different organization | - | |||||
Health care agencies provide funding for a fixed number of clients but caseloads of case managers often exceed that number | - | ||||||
Indistinct quality demands on case manager tasks | - | - | |||||
No agreement on the content of the care plan and no uniform registration system | - | ||||||
Organizational structure
| |||||||
Meso level
|
Facilitating
| Guarding and continuing the integration of case management. Preconditions are: well profiled case management, good collaboration between partners and overall satisfaction of case management by partners | + | + | |||
A platform of directors of dementia network partners who can develop new initiatives in case management | + | ||||||
Creating a production plan for municipalities to provide insight into what type of care they purchase | + | ||||||
Impeding
| No clear referral procedures | - | |||||
Not documenting what happens to responsibilities for organizational tasks on a structural basis | - | ||||||
A change in the board or employees in dementia network partners can change their motivation | - | ||||||
Collaboration with dementia care partners
| |||||||
Meso level
|
Facilitating
| Transparency about case management practice towards dementia partners | + | + | |||
Regular meetings with social psychiatric nurses from Mental Health Care to discuss and solve collaboration issues | + | ||||||
Exchanging knowledge between case managers and other disciplines increases cohesion | + | ||||||
Using existing collaboration networks to build on, e.g. networks between general practitioners and district nurses | + | ||||||
Collaboration with general practitioners, home care and day care centers can be strengthened by being each other's eyes and ears | + | ||||||
Impeding
| Partners have difficulty seeing case managers as equivalent to social psychiatric nurses, with whom they have experience | - | |||||
No collaboration between the municipalities and the health care agency | - | - | |||||
Lack of transparency about division of funding from health care agencies to case management providers | - | ||||||
Quality of care
| |||||||
Meso level
|
Facilitating
| Staying focused on individual needs of clients when discussing with care partners | + | + | |||
Commitment of the Alzheimer's Association + delegation of patients and case managers | + | + | |||||
Impeding
| Influence of the government who advocates primary care and care that is not disease specific | - | |||||
As social psychiatric nurses hand over clients and tasks to case managers they lose touch with psychogeriatrics and the social chart even though clients would benefit from good collaboration between case managers and social psychiatric nurses | - | ||||||
Referral by case managers based on competing interests of providers instead on what clients need. | - | - | |||||
Law & legislation/Financing
| |||||||
Meso level
|
Impeding
| Regions made up the balance too late for an effective transfer of funds from regions with an excess of funds | - | ||||
Financial agreement that case management can only start after diagnosis | - | ||||||
Smaller municipalities can easily drop their funding when the pressure rises, creating a gap | - | ||||||
Without project funding administrational support for case managers was dropped | - | ||||||
Macro level
|
Facilitating
| Pilot funding gave regions space to develop case management (but also caused a diversity in practice) | + | ||||
Part of the financing from Mental Health Care could be adopted for case management | + | ||||||
Introduction of the DBC: it included tasks that case managers perform | + | + | |||||
Redistributing funding across regions by health care agency based on needs of regions | + | ||||||
Impeding
| As project funding ended, project leaders and coordination points were omitted | - | |||||
Lack of full insurance cover for case management led to fragmentation of financial support | - | ||||||
In some regions diagnostics and treatment are funded by the Health Insurance Act, but not in all of them | - | ||||||
DBC does not cover all case management tasks | - |