Implementing Case Management – understanding principles and learnings from complex adaptive systems.
This is a very important case study (1) demonstrating the unintended
consequences resulting from health service decision makers implementing
‘simple’ and/or ‘complicated’ interventions in a health system that is
‘complex’. (2) The buying an ‘off the shelf’ solution to the care
management and coordination needs of frail, ill older patients seems like
a good idea – all that is required is some local process adaptation and
the product will deliver the desired outcomes anywhere, as long as it has
been demonstrated the intervention is effective. Yet in the case of
Evercare, the implementation did not deliver the intended outcomes. (1)
A rush of reflection follows, culminating with the authors’
conclusions: “in an ideal world, randomised controlled trials should be
undertaken before introducing policies with potentially large health and
cost consequences”. (3) In fact, it appears that according to these
methodological criteria (which originally were designed to apply to simple
technologies such as lithotripsy machines), not only this evaluation
study, but also the original Evercare study were not properly evaluated.
Furthermore, most of the existing evidence has limited external
generalisability, because “the literature suggests that the effects of an
intervention depend heavily on the context in which it is introduced.”(3)
Thus it doesn’t matter how many randomized controlled trials (RCT) or
other study types are conducted, their findings will lack external
generalisability because of widely varying health service contexts and
different actors. However, such studies are useful, in as much as a high
level policy synthesis of the findings indicate that the principles of
case management are valid and can meet the needs for complex care for
frail ill patients. Success is based on local context, local actors and
the mode of implementation. Using a complexity approach, once the
principles are accepted as valid and desirable to introduce to an
organization, the most relevant research is to develop an understanding
(often through qualitative evaluation) about what worked, what didn’t, and
where and why etc.. In fact, this reflects a major component of the
response by the authors. (3)
So where does that leave us?
Is it rationale to buy an ‘off the shelf’ product for health service
reform like one would buy a vacuum cleaner and by merely using an adapter
plug, have a product that works in many different countries and settings?
Of course not! Case management is an intervention in a health care system
based on principles of care coordination and management with the aim to
improve quality of care and life for an at risk population. (4) However a
health care system behaves like a complex adaptive system, it best
organizes itself through a ‘bottom up’ approach. Hence what matters in
terms of implementation of a case management system is: clear and valid
policy and principles; local ownership and buy in; assessment of the
health care system capacity and functionality to respond to the needs of
frail people; and customization to address the local community
characteristics. (5)
To this end, interestingly, the first round of Australian Coordinated
Care trials demonstrated these key points. Every one of the 9 local trials
experimented with different locally determined processes to meet community
needs for care coordination. The RCTs proved a nightmare in methodological
terms because there was such diversity in capacity, needs and
implementation in each local setting. RCT outcomes evaluation was
problematic despite a core data set and central rules across the trials.
The major learnings were the about the processes of local needs
assessment, understanding of the how local systems worked and how they
might be improved in future. (4)
We are left with compelling knowledge - both tacit and explicit -
that we ought to look at health systems as complex adaptive wholes with an
‘in-built’ property to adapt and emerge in multi ways to the same
stimulus. Understanding different systems adaptation to case management
policy and principles and how to transfer such knowledge to other settings
should be the aim of research. Complex systems are organic and respond to
planting seeds and nurturing existing strengths rather than the
imposition of obvious ‘simple’ top down solutions.(2) However time is
needed to allow the system to adapt and grow in new directions.(5)
(1) Gravelle H, Dusheiko M, Sheaff R, Sargent P, Boaden R, Pickard S,
et al. Impact of case management (Evercare) on frail elderly patients:
controlled before and after analysis of quantitative outcome data. BMJ
2007; Jan 6;334(7583):31.
(2) Glouberman, S 2001 Towards a New Perspective on Health Policy:
Final Report CPRN Study No. H|03 www.healthandeverything.org
(3) Martin Roland, et al.Authors' response bmj.com, 31 Jan 2007
(4) Esterman AJ, Ben-Tovim DI. The Australian coordinated care
trials: success or failure? The second round of trials may provide more
answers. Med J Aust. 2002 Nov 4;177(9):469-70.
(5) Sturmberg JP and Martin C. Primary Care reforms – a complex
adaptive system in Sturmberg JP The Foundations of Primary Care. Daring to
be different. Radcliffe Medical Press 2007.
Competing interests:
None declared
Competing interests:
No competing interests
07 February 2007
Carmel M Martin
Associate Professor of Family Medicine
Joachim P Sturmberg
Northern Ontario School of Medicine, Canada K1N 5E3
Rapid Response:
Implementing Case Management – understanding principles and learnings from complex adaptive systems.
This is a very important case study (1) demonstrating the unintended
consequences resulting from health service decision makers implementing
‘simple’ and/or ‘complicated’ interventions in a health system that is
‘complex’. (2) The buying an ‘off the shelf’ solution to the care
management and coordination needs of frail, ill older patients seems like
a good idea – all that is required is some local process adaptation and
the product will deliver the desired outcomes anywhere, as long as it has
been demonstrated the intervention is effective. Yet in the case of
Evercare, the implementation did not deliver the intended outcomes. (1)
A rush of reflection follows, culminating with the authors’
conclusions: “in an ideal world, randomised controlled trials should be
undertaken before introducing policies with potentially large health and
cost consequences”. (3) In fact, it appears that according to these
methodological criteria (which originally were designed to apply to simple
technologies such as lithotripsy machines), not only this evaluation
study, but also the original Evercare study were not properly evaluated.
Furthermore, most of the existing evidence has limited external
generalisability, because “the literature suggests that the effects of an
intervention depend heavily on the context in which it is introduced.”(3)
Thus it doesn’t matter how many randomized controlled trials (RCT) or
other study types are conducted, their findings will lack external
generalisability because of widely varying health service contexts and
different actors. However, such studies are useful, in as much as a high
level policy synthesis of the findings indicate that the principles of
case management are valid and can meet the needs for complex care for
frail ill patients. Success is based on local context, local actors and
the mode of implementation. Using a complexity approach, once the
principles are accepted as valid and desirable to introduce to an
organization, the most relevant research is to develop an understanding
(often through qualitative evaluation) about what worked, what didn’t, and
where and why etc.. In fact, this reflects a major component of the
response by the authors. (3)
So where does that leave us?
Is it rationale to buy an ‘off the shelf’ product for health service
reform like one would buy a vacuum cleaner and by merely using an adapter
plug, have a product that works in many different countries and settings?
Of course not! Case management is an intervention in a health care system
based on principles of care coordination and management with the aim to
improve quality of care and life for an at risk population. (4) However a
health care system behaves like a complex adaptive system, it best
organizes itself through a ‘bottom up’ approach. Hence what matters in
terms of implementation of a case management system is: clear and valid
policy and principles; local ownership and buy in; assessment of the
health care system capacity and functionality to respond to the needs of
frail people; and customization to address the local community
characteristics. (5)
To this end, interestingly, the first round of Australian Coordinated
Care trials demonstrated these key points. Every one of the 9 local trials
experimented with different locally determined processes to meet community
needs for care coordination. The RCTs proved a nightmare in methodological
terms because there was such diversity in capacity, needs and
implementation in each local setting. RCT outcomes evaluation was
problematic despite a core data set and central rules across the trials.
The major learnings were the about the processes of local needs
assessment, understanding of the how local systems worked and how they
might be improved in future. (4)
We are left with compelling knowledge - both tacit and explicit -
that we ought to look at health systems as complex adaptive wholes with an
‘in-built’ property to adapt and emerge in multi ways to the same
stimulus. Understanding different systems adaptation to case management
policy and principles and how to transfer such knowledge to other settings
should be the aim of research. Complex systems are organic and respond to
planting seeds and nurturing existing strengths rather than the
imposition of obvious ‘simple’ top down solutions.(2) However time is
needed to allow the system to adapt and grow in new directions.(5)
Carmel M Martin and Joachim P Sturmberg
carmel.martin@NorMed.ca
References
(1) Gravelle H, Dusheiko M, Sheaff R, Sargent P, Boaden R, Pickard S,
et al. Impact of case management (Evercare) on frail elderly patients:
controlled before and after analysis of quantitative outcome data. BMJ
2007; Jan 6;334(7583):31.
(2) Glouberman, S 2001 Towards a New Perspective on Health Policy:
Final Report CPRN Study No. H|03 www.healthandeverything.org
(3) Martin Roland, et al.Authors' response bmj.com, 31 Jan 2007
(4) Esterman AJ, Ben-Tovim DI. The Australian coordinated care
trials: success or failure? The second round of trials may provide more
answers. Med J Aust. 2002 Nov 4;177(9):469-70.
(5) Sturmberg JP and Martin C. Primary Care reforms – a complex
adaptive system in Sturmberg JP The Foundations of Primary Care. Daring to
be different. Radcliffe Medical Press 2007.
Competing interests:
None declared
Competing interests: No competing interests