Objective

Health systems are expanding efforts to address health and social risks, although the heterogeneity of early evidence indicates need for more nuanced exploration of how such programs work and how to holistically assess program success. This qualitative study aims to identify characteristics of success in a large-scale, health and social needs case management program from the perspective of interdisciplinary case managers.

Setting

Case management program for high-risk, complex patients run by an integrated, county-based public health system.

Participants

30 out of 70 case managers, purposively sampled to represent their interdisciplinary health and social work backgrounds. Interviews took place in March-November 2019.

Primary and secondary outcome measures

The analysis intended to identify characteristics of success working with patients.

Results

Case managers described three characteristics of success working with patients: (1) establishing trust; (2) observing change in patients' mindset or initiative and (3) promoting stability and independence. Cross-cutting these characteristics, case managers emphasised the importance of patients defining their own success, often demonstrated through individualised, incremental progress. Thus, moments of success commonly contrasted with external perceptions and operational or productivity metrics.

Conclusions

Themes emphasise the importance of compassion for complexity in patients' lives, and success as a step-by-step process that is built over longitudinal relationships.

Background

Social needs case management programs are a strategy to coordinate social and medical care for high-risk patients. Despite widespread interest in social needs case management, not all interventions have shown effectiveness. A lack of evidence about the mechanisms through which these complex interventions benefit patients inhibits effective translation to new settings. The CommunityConnect social needs case management program in Contra Costa County, California recently demonstrated an ability to reduce inpatient hospital admissions by 11% in a randomized study. We sought to characterize the mechanisms through which the Community Connect social needs case management program was effective in helping patients access needed medical and social services and avoid hospitalization. An in-depth understanding of how this intervention worked can support effective replication elsewhere.

Methods

Using a case study design, we conducted semi-structured, qualitative interviews with case managers (n = 30) and patients enrolled in social needs case management (n = 31), along with field observations of patient visits (n = 31). Two researchers coded all interview transcripts and observation fieldnotes. Analysis focused on program elements identified by patients and staff as important to effectiveness.

Results

Our analyses uncovered three primary mechanisms through which case management impacted patient access to needed medical and social services: [1] Psychosocial work, defined as interpersonal and emotional support provided through the case manager-patient relationship, [2] System mediation work to navigate systems, coordinate resources, and communicate information and [3] Addressing social needs, or working to directly mitigate the impact of social conditions on patient health.

Conclusions

These findings highlight that the system mediation tasks which are the focus of many social needs assistance interventions offered by health care systems may be necessary but insufficient. Psychosocial support and direct assistance with social needs, enabled by a relationship-focused program, may also be necessary for effectiveness.