Home Care Case Managers' Integrated Care of Older Adults with Multiple Chronic Conditions: An Institutional Ethnography

  • Author / Creator
    Garland Baird, Lisa Marie
  • Background: Over 90% of Canadians age 65 and over live at home or in community assisted living settings. Of this, 33% have two or more chronic conditions, with one in six of this population receiving home care services. Multi-morbidity is a predictor of decreased quality of life, premature mortality, and increased health care use. Home care case managers (HCCMs) strive to provide safe, quality, and integrated care for older adults with multiple chronic conditions (MCCs) in home settings. HCCMs’ day-to-day experiences and work are socially organized by institutional discourses and processes of health systems and home care programs. How integrated care is known and organized in health and home care settings, contradicts and complicates HCCMs’ work of providing actual integrated care for older adults with MCCs.
    Purpose: The purpose of this dissertation was to explore the knowledge and practice of integrated care from the standpoint of HCCMs—and the authoritative institutional arrangements and discourse within which HCCMs’ work is organized—to explicate how HCCMs provide, or not provide, integrated care for older adults with MCCs.
    Methods: A scoping literature review was used to examine qualitative, quantitative, and mixed-methods research to explore how case management standards of practice correspond with functions of integrated care and identify facilitators and barriers to case management and integrated care delivery. Institutional ethnography was used for a qualitative inquiry that explored and explicated the social organization of HCCMs’ work of providing integrated care to older adults with MCCs.
    Findings: Findings demonstrated that HCCMs use case management standards and integrated care functions at the professional and clinical levels. Although case management standards and integrated care functions were found to be both facilitators and barriers, they were more likely to facilitate HCCMs’ work. HCCMs’ use of professional and clinical integrated care functions was inconsistent and varied based on use of standards. Findings showed that HCCMs’ work was socially organized by institutional arrangements of health systems and home care programs that created points of tension for HCCMs. HCCMs’ provision of integrated care was organized into three activities: documenting case management work, communicating with interdisciplinary team members external to home care, and creating “work-arounds” to provide integrated care. HCCMs’ work, was seemingly guided by the philosophy and approaches of integrated care. However, health system ruling relations and discourses of business process management, cost containment, and efficiency, were organizing HCCMs' work in ways that were contradictory to the goals of integrated care. How these processes and texts operated together revealed a complex picture of how HCCMs’ care of older adults with MCCs was organized to happen as it did.
    Implications: The social organization of integrated care within the institutional arrangements of health systems and home care programs created work environments, by which HCCMs, who were nurses, experienced their knowledge and experience in contrast to the management processes that were applied to their work. Textual organization of nurses’ work subordinates and renders nurses' actual knowledge and experiences invisible within health care, and in the creation of nursing knowledge. The privileging of dominant managerial discourses that undermine the principles of integrated care creates inequities in the delivery of nursing practice and integrated care for older adults with MCCs.

  • Subjects / Keywords
  • Graduation date
    Fall 2018
  • Type of Item
  • Degree
    Doctor of Philosophy
  • DOI
  • License
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