Case management in a fragmented health and social care ecosystem: An exploration of community-based services for older people in Ireland

Introduction: The extant literature frequently points to the difficulties of effectively responding to the needs of older people due to structural and policy legacies which have resulted in resource discrepancies in health and social care systems, causing fragmentation and a lack of coordination across systems. At a micro level, frequently, case management interventions are adopted to facilitate a continuum of care and related coordination of care across systems. There is, however, a dearth of information on whether and how different case management models and intensities of service provision are responsive to, and shaped by, these structural disparities. Aim: Focusing on the micro delivery of integrated care interventions, this study aimed to elucidate professionals’ (working as part of three separate Community Specialist Teams (CSTs) delivering integrated care programmes in Ireland) adoption and implementation of a case management approach and explore the multiple factors shaping such approaches and their associated outcomes. Methods: The study comprised a multiple, case study design. 22 service providers engaged in semi-structured interviews including case managers, medical, nursing, allied health and administrative professionals from three purposefully selected CSTs operating different models of case management. Data generation and analysis were sensitively informed by key concepts of Chaudoir’s Multi-level Health Innovation Model enabling insight into the variety of structural and patient factors which influence the nature, scope and intensity of case management. Findings: Local health and social care infrastructures and associated resources determined to what degree a case manager’s work could be defined as a needs-led as opposed to a resource or system’s-led intervention. In contexts where community and social care organisations were well resourced, innovative partnerships across the health and social care system resulted which had the potential to lead to more optimum outcomes for older persons’ health, wellbeing and welfare. Conversely, in locations where these ancillary community supports were limited, the capacity of the case manager to engage in meaningful partnerships with wider health and social care services was curtailed. These distinctions, clearly pointed to two diverse models of case management, that is an intensive, strengths-based model and a brokerage, signposting model. In the former, a greater extent of integration and optimal delivery of bio-psychosocial care for older people was possible. Conclusions: Results indicate that regional resource disparities in Ireland, directly impact the extent to which case managers can nurture partnerships across health and social care systems and in turn the degree to which the multidimensionality of older people’s care needs can be met. The transformative potential of the case manager is constrained in contexts of primary care system fragmentation, restricted respite beds and inadequacies and underfunding of the domiciliary and community care sector. While focused on the Irish system of community services for older people, the findings offer learnings to jurisdictions enacting case management as a key mechanism of integration and to policy makers espousing calls for greater integration of older people’s community services.