A realist evaluation of an integrated care program in primary care for individuals with complex needs

Case management (CM) is an integrated care program designed to improve health outcomes for individuals with complex needs while reducing healthcare utilization and cost. This study examines how and why CM works in primary care for individuals with complex needs. A realist evaluation was conducted using a qualitative design. An initial program theory was developed in alignment with the study’s objective to guide data collection and analysis. Twenty-four individual interviews and three focus groups were conducted with case managers, patients, clinic managers, and providers from seven participating primary care clinics across New Brunswick, Nova Scotia, Newfoundland and Labrador and Quebec (Canada), between February 2022 and May 2023. Data analysis focused on identifying context-mechanism-outcome (CMO) configurations and recurring patterns known as demi-regularities. Twelve CMO configurations were identified, highlighting key mechanisms: (1) case managers built mutual trust with individuals, felt accountable, and were integrated into interdisciplinary teams; (2) clinic teams collaborated and valued interprofessional work; (3) individuals felt supported, informed about their health status, and empowered; and (4) families felt supported, respected and included. Two demi-regularities emerged: (1) individuals engaged in their care and gained control over their health through trusting relationships with case managers; and (2) providers enhanced teamwork and care delivery through their commitment to and engagement in the CM program. This study highlights the importance of trust-building, empowerment, interprofessional collaboration, and supportive organizational and policy environments for the implementation of CM which can enhance self-management, improve patient health outcomes, strengthen teamwork, coordination and collaboration, reduce workload, and improve quality of care. Building trust is the cornerstone of effective case management (CM). Case managers should build strong, trusting relationships with patients, families, and care teams to enhance self-management and improve health outcomes. Empowerment drives better care. Case managers should actively involve patients and families in decision-making to foster collaboration and ensure care plans reflect their needs and preferences. Successful CM implementation requires systemic support. Healthcare organizations should promote interprofessional collaboration, and policymakers can reinforce commitment by addressing compensation models.