In plain language, what is your project about? What questions are you trying to answer by doing this research?
Individuals with chronic health conditions and complex healthcare needs require a range of services from various systems (e.g. health, social, education) and community networks. To integrate all of the programs from different systems to meet someone’s needs is often challenging, and difficulties in providing coordinated care to these individuals places them at an increased risk for disability, early death, and a lower quality of life.
One solution to this problem is case management. It’s a collaborative approach to care that is used to assess, plan, facilitate, and coordinate all of the services needed to meet individual patients’, and their families’, healthcare needs. Case management also provides patients with regular follow up by a nurse within their primary care provider’s practice.
For this project, we are part of a larger team that will first implement case management in primary care clinics in urban and rural communities across Canada, and then evaluate it from both the perspective of the individual as well as the healthcare system. The case manager starts with assessing a patient’s individual needs and preferences for care, and then works with the patient, their family, and/or other partners, to develop and maintain a custom plan for accessing the various services that they need. The case manager then coordinates the services among all of the organizations providing the required services, as well as provide the patient and their families with continuing education and support for managing one’s health.
When the project is completed, we hope to know:
As well, we hope that participating in the project improves our patients’ experiences and outcomes with the healthcare system, increases their self-management, and reduces any unnecessary visits to the emergency room.
It’s a new partnership, but our respective interests in improving care at the primary care level are squarely aligned, so we’re all hopeful that this first project will help accelerate increased opportunities for collaboration and knowledge translation activities.
How – if at all – has the COVID-19 pandemic changed your research project and/or collaboration
It has been challenging from an operational perspective. Many of the community health centre clinicians were reallocated to support the collective pandemic response within Horizon, specifically for COVID testing. And, because of the pandemic, we have had to incorporate telehealth as a way to implement case management. Both of these factors led to delays in implementing the project, and to some extent, continues to impact our team’s focus on the project – especially with the dedicated time to focus on core project tasks, such as bringing in new clients. What we’ve found to be important throughout these challenging times is maintaining consistent communication and keeping everyone informed on the changes that have resulted due to the pandemic.
What advice would you give to others on building a successful research collaboration?
As mentioned earlier, an essential component to building a successful research collaboration is maintaining consistent communication, especially given that we have different research and clinical priorities. Regular updates, whether in person or via an online platform, ensures that issues are resolved and everyone stays on the same page. This is also crucial to ensure that everyone is up-to-date with the steps and timelines of the research project, and understands the capacity and speed at which the healthcare system can implement a new initiative while simultaneously managing other operational challenges present. Clear and focused communication is also important in building a team environment where everyone is comfortable discussing their concerns, addressing questions as they arise, and sharing successes.
This project, Case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs: Implementation and realist evaluations, is a pan-Canadian study funded through the Canadian Institutes for Health Research (CIHR) and other matching partners (totaling $2.2 million, of which $200,000 came from the New Brunswick Health Research Foundation), and has Dr. Doucet as a co-principal investigator. The team continues to implement the case management program in the clinics; their implementation and evaluation protocol was published in 2018, and we will update this post with results once available.
Director, Primary Health Care Program (Saint John Area), Horizon Health Network
Shelley Doucet, RN, BN, MScN, PhD
Jarislowsky Chair in Interprofessional Patient-Centred Care
Associate Professor, Department of Nursing & Health Sciences
Director, Centre for Research in Integrated Care, UNB Saint John
Alison Luke, PhD
Research Associate, Centre for Research in Integrated Care, UNB Saint John
Charlotte Schwarz, MA
Project Coordinator, Centre for Research in Integrated Care, UNB Saint John
Research Assistant, Centre for Research in Integrated Care, UNB Saint John