SPOR PIHCI Programmatic Grant: Case Management in Primary Care for Frequent Users of Healthcare Services with Chronic Diseases and Complex Care Needs: Implementation and Realist Evaluations

Individuals with chronic conditions and complex healthcare needs require a range of services from various systems (e.g. health, social, education) and community networks. This often leads to difficulties with the integration of care. One solution to address the frequent use of healthcare services and improve the integration of care is case management (CM). CM is a collaborative approach used to assess, plan, facilitate, and coordinate care to meet individual/patient and family healthcare needs across all sectors to improve individual and health system outcomes. Over the past five years, members from our research team in Québec evaluated a CM intervention in primary care tailored for individuals/patients with chronic conditions who frequently use healthcare services. Our research team is employing this CM intervention to answer the following research questions: 1) What are the facilitators and barriers of CM implementation in primary care clinics across Canada? 2) What are the relationships between the actors, contextual factors, mechanisms, and outcomes of the CM intervention? 3) What are the next steps towards scalability (expansion within similar contexts and extension to different contexts) across Canada? 


The CM intervention will be implemented in 10 primary care clinics across 5 Canadian provinces (QC, NB, SK, NL, and NS). In NB, we will implement the intervention at the St. Joseph's Community Health Centre and Harbour Health, both in Saint John. This project has the potential to improve the experience and health status for Canadians who are frequent health system users with complex healthcare needs, as well as improve the performance of healthcare systems, curbing ineffective use and costs. I am a Co-Principal Investigator of this pan-Canadian four-year study funded by CIHR and other matching partners totaling $2,000,000.