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

I am a Co-Principal Investigator of this pan-Canadian four-year study funded by CIHR and other matching partners totaling $2,000,000. The goals of our project are to: 1) generate findings on the implementation of case management in primary care for individuals with chronic conditions and complex healthcare needs who frequently use healthcare services; and 2) implement an evidence-based case management intervention that will improve care experiences and outcomes, and reduce the use of healthcare services by these individuals and the related costs. 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. These individuals are at greater risk for disability, reduced quality of life, and increased mortality.


Case management (CM) is a collaborative approach used to assess, plan, facilitate, and coordinate care to meet patient and family healthcare needs. This is achieved through communication and coordinating access to available resources and services across all levels of health care (such as community, primary, secondary and tertiary care), as well as sectors outside of the health system (such as social services, housing, etc.), with the intent to improve individual and health system outcomes. Implementation of CM directly within primary care settings fosters close interactions between the individual/patient, the Case Manager and the primary care team.


Members of our research team have implemented and evaluated CM in Quebec primary care clinics over the past five years. Patients and their families have reported a positive experience regarding care integration. This intervention is rarely implemented in primary care across Canada. For CM to become standard practice in primary care in different jurisdictions, stakeholders including patients need to be engaged in adapting the intervention to their own context. Therefore, further research is required to better understand the facilitators and barriers of CM implementation in primary care, including the influence of different provincial primary care contexts on outcomes (e.g. self-management, quality of life, services integration, services use, and costs).


This project aims to address this gap by implementing the CM model in ten primary care practices, with two practices in each of the partnering provinces (QC, NB, SK, NL, and NS). In NB, we will be implementing the CM model in two Horizon Health Network primary care clinics. Results will provide a detailed and highly practical understanding of CM that will be invaluable to plan and implement CM at local, regional, and national levels, towards a more effective, integrated, and efficient healthcare structure that supports better experience and improved care.