Case management programs for people with complex needs: Towards better engagement of community pharmacies and community-based organisations.

INTRODUCTION: The objectives of this study were 1) to describe how case management programs engaged community pharmacies and community-based organisations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement.
METHODS: Using a descriptive qualitative design, individual interviews and focus groups with patients, healthcare providers and managers were analysed according to a mixed thematic analysis based on a deductive (Rainbow Model of Integrated Care) and an inductive approach. RESULTS AND DISCUSSION: Participants highlighted the individualized service plan as a significant tool to foster a shared person-focused vision of care, information exchanges and concerted efforts. Openness to collaboration was also considered as an enabler for community stakeholders' engagement. The lack of recognition of community-based organisations by certain providers and the time required to participate in individualized service plans were outlined as barriers to professional integration. Limited opportunities for community stakeholders to be involved in decision-making within case management programs were reported as another constraint to their engagement. Cultural differences between organisations regarding the focus of the intervention (psychosocial vs healthcare needs) and differences in bureaucratic structures and funding mechanisms may negatively affect community stakeholders' engagement. Formal consultation mechanisms and improvement of communication channels between healthcare providers and community stakeholders were suggested as ways to overcome these barriers.
CONCLUSION: Efforts to improve care integration in case management programs should be directed toward the recognition of community stakeholders as co-producers of care and co-builders of social policies across the entire care continuum for people with complex needs.

Introduction

People with complex care needs are characterized by multiple chronic diseases, mental health comorbidities and/or social vulnerabilities [1]. These individuals are at greater risk for adverse health outcomes, reduced quality of life and increased mortality [2, 3]. They constitute a small heterogeneous group (10% of all users) that generates disproportional costs (70%) for the health system in Canada as in many industrialized countries [4, 5]. Their high use of emergency department services and hospitalizations [5-7] is generally due to fragmented and episodic care between healthcare services [8, 9]. As a result, providing appropriate services that meet the needs of this population is required and can be achieved through integrated care. Integrated care is “the search to connect the healthcare system (acute, primary medical, and skilled) with other human service systems (e.g. long-term care, education, and vocational and housing services) in order to improve outcomes (clinical, satisfaction, and efficiency)” [10]. Case management programs (CMPs) are increasingly used to improve the integration of services [11, 12]. Defined as ‘collaborative, client-driven processes for the provision of quality health and support services through the effective and efficient use of resources’ [13], their benefits for patients include the improvement of self-management skills, adherence, satisfaction, health status and quality of life. CMPs also benefit the healthcare system by improving the quality of care and reducing healthcare use and cost [14-18].

In Quebec (Canada), community-based organisations (CBOs) and community pharmacies are primary care services linked by formal and informal arrangements to healthcare organisations [19].

CBOs are non-profit organisations that work for social development in their communities [20]. and may include volunteer associations, cooperatives and social economy enterprises whose funding comes from various sources (federal and provincial governments, foundations, donations, social economy, etc.) [21]. Their missions focus on social development, advocacy, housing, and recreation. The populations that they target may include youth, families, indigenous groups, LGBTQ+, people with poor mental health or disabilities, refugees, homeless individuals and immigrants. Their intervention approaches are diverse and include health promotion, informal intervention, outreach work, harm reduction, empowerment, group therapy, and person-focused approaches. As local and collective initiatives, the majority of CBOs focus on community needs, with governance that is based on autonomous and democratic principles, usually involving a board of directors mandated by an assembly of representatives who supervises employee activities and the organisation’s strategic orientation [22].

Community pharmacies are private organisations committed to maintaining the overall health of their patients through a variety of interventions: medical information review and treatment follow-up, preparation of medication, adjustment and initiation of treatment, and daily consultations with people who have questions [23]. Community pharmacists are indispensable partners for patients with polypharmacy [24, 25]. They educate and advise people on the use of over-the-counter or prescribed medication and natural health products; support people seeking solutions to minor health problems; contribute to patients’ education regarding healthy lifestyles; and if necessary, refer patients to other health and social services [23].

Research has demonstrated the need for and benefits of engaging CBOs and community pharmacies in hospitals or primary care programs, such as CMPs, for people with complex care needs [26-28]. These community stakeholders, who are deeply rooted in their communities, can facilitate a close connection with people who live in the surrounding area [29]. As such, they can contribute significantly to identifying people with complex care needs [27] and to supporting them as they navigate the health system [30]. Furthermore, most CBOs offer person-focused interventions that target behavioural issues or functional difficulties (e.g. harm reduction, education on healthy lifestyle), which may be an effective component of CMPs, especially if linked to healthcare delivery [30]. Fig 1 illustrates the relationships between the stakeholders engaged in these programs for patients with complex needs.

Fig 1

Relationships between stakeholders engaged in CMPs.

Despite this evidence, the collaboration between providers from the healthcare system and community stakeholders remains poor due to healthcare professionals’ lack of knowledge about CBOs and community pharmacies [31], resulting in low CMP referral rates, complexity of managing multi-organisational initiatives, variable adherence to the programs [26] and poor care transition leadership [30]. Disparities in financial resources, organisational expertise and knowledge, lack of proximity between organisations, differences in the vision of collaboration, and complexity of managing communication and information flow across organisations are other issues that can challenge alliances [32].

It is now recognized that CMPs can help bridge the gap between institutional and community care, and that inter-organisational collaboration, as proposed by these programs, could help “service organisations to shift from traditional ‘silo’ models of service delivery to increased community-based collaboration and service coordination” [33]. Yet, evidence regarding integrated care in the context of CMPs from stakeholders’ perspective remains limited [28, 33–35]. The objectives of this study are: 1) to describe how CMPs engaged community pharmacies and CBOs in a perspective of integrated care for people with complex needs, and 2) to identify engagement enablers, barriers, and potential strategies to overcome these barriers.

Conceptual framework

The Taxonomy for Integrated Care [36] based on the theoretical foundations of the Rainbow Model of Integrated Care [37] was used in this study. The Rainbow Model of Integrated Care plays interconnected roles at the macro (system integration), meso (organisational and professional integration), and micro (clinical integration) levels, as well as between these levels (functional and normative integration). It was developed from electronic database searches, hand searches of reference lists (snowball method) and by contacting researchers in the field [37]. Thereafter, a literature review and thematic analysis procedure were conducted to refine the model into the taxonomy of fifty-nine key features that helps to profile integrated care initiatives [36]. By developing an international consensus-based taxonomy based on Delphi studies [38] and including every level and stakeholders’ perspectives of integrated care, Valentijn et al.’s research has become a reference in the field of integrated care.

At the macro level, system integration refers to the alignment of rules and policies within a system to ensure the provision of continuous, comprehensive, and coordinated services across the entire care continuum [37]. At the meso level, organisational and professional integrations refer to the extent to which organisations and healthcare providers respectively coordinate services across organisations and disciplines. These types of integration processes are especially relevant “in socially disadvantaged populations, such as those with large variations in wealth, education, culture and access to healthcare” [39]. At the micro level, clinical integration is related to how care services are coordinated, share a single process for person-focused coordination of care across time, places and disciplines, and reflect a bio-psychosocial perspective of health. This person-focused coordination taking into account the broader health context is particularly relevant for people with complex healthcare needs that span a large number of service areas [37]. Clinical integration also encompasses the important aspect of the patient as a co-creator in the care process and shared responsibility between the provider and the person [40].

Functional and normative integration are cross-cutting types of integrated care processes linking macro, meso, and micro levels [37]. Functional integration links financial, management and information systems around the primary process of service delivery across clinical, professional, organisational and system integration. Normative integration implies the development and maintenance of a common frame of reference (i.e. shared mission, vision, values and culture) between organisations, professional groups and individuals.

Material and methods

Design

A descriptive qualitative design [41] was used. This approach helps to provide a full description of the individuals’ experience, perceptions, and knowledge of the CMPs, in plain language while remaining close to the data and minimizing researcher influence on data interpretation [42, 43]. It helped to obtain a better understanding of the stakeholders’ engagement (strategies, barriers and facilitators) in a perspective of integrated care.

Settings

This study was developed as part of the developmental evaluation of a CMP in the Integrated University Health and Social Services Centre (hereafter called ‘hospital network”) located in the Saguenay-Lac-Saint-Jean region of the province of Québec (Canada) [12]. This hospital network is composed of six health and social services centres (hereafter called ‘hospital’), each including a hospital, community and long-term care centres, a child and youth protection centre, and a rehabilitation centre to ensure access, continuity, coordination and the quality of services intended for the population of their local territories [44]. Patients eligible for the CMP had complex needs and had made six or more visits to the emergency department, or had three or more hospitalizations in the previous year. The study was conducted in partnership with hospital network decision makers and a variety of stakeholders [12].

Between 2008 and 2015, the CMP for patients with complex care needs was deployed in all of the hospitals within the hospital network. The program comprised four main components: 1) evaluation of patient needs and goals; 2) development of a patient-centred individualized service plan [45]; 3) care coordination among all partners; and 4) education and self-management support for patients and families [12]. The individualized service plan was planned by the case manager after obtaining the patient’s consent. It involved all stakeholders in a meeting, including the patient, primary care providers, secondary and tertiary care providers, community pharmacists, CBO representatives (typically social workers) and the case manager, to detail the patient’s needs (including an orientation regarding the action plan for each need) and person-focused shared objectives as well as the services allocated in response to these needs and objectives [45]. The case manager was mandated to validate, share and ensure the follow-up of the individualized service plan with the concerned stakeholders. The aim of the case manager’s intervention was to improve quality of life and self-management for patients, and for organisations, it aimed to improve care integration and support for healthcare teams to reduce inappropriate use of services and costs [12].

Data collection and characteristics of participants

Key informants involved in the CMPs were recruited through purposeful sampling [46] in the six hospitals between December 2014 and May 2018. Patients recruited for the study met the program’s eligibility criteria, i.e. frequent users of hospital services who had six or more visits to the emergency department, or three or more hospitalizations in the previous year. Patients were approached by their case manager to participate in the study. Those who verbally consented to participate were referred by their case manager to the research team. The research team members then contacted the patients by phone to make an appointment for an individual interview. The researchers’ knowledge of the hospital network’s organization helped them identify managers, clinicians and community pharmacists. CBO representatives were identified with the help of case managers [46]. Research assistants explained the research project to them as part of the first contact by phone or email. An appointment was then made for the individual interview or focus group.

Individual interviews and focus groups were both used as qualitative data collection methods to promote participation and facilitate exchanges. Individual interviews aim to thoroughly explore each participant’s views, experiences, beliefs, and knowledge, while focus groups use group dynamics to highlight the variation of viewpoints held in the targeted population [47]. Focus groups were used as an alternative method to individual interviews, gathering selected types of actors to facilitate their participation, before or after one of their scheduled meetings. One-hour individual interviews (n = 58 participants) were conducted with people with complex care needs (n = 25), managers, case managers and coordinators (n = 13), family physicians (n = 16), and community pharmacists (n = 4). Focus groups (n = 13, including 71 participants) lasting between 45 and 90 minutes were conducted with managers and case managers (n = 4, including 22 participants), family physicians (n = 2, including 16 participants), nurses (n = 1, including three participants), community pharmacists (n = 2, including five participants) and CBO representatives (n = 4, including 25 participants). Table 1 presents the characteristics of the participants. The focus groups included two to eight participants. A total of seven to nine participants provides a balance between the number of interactions by participants and the variation of experiences and opinions, while more specialized topics work best with groups of five or six participants [47]. The small size of certain focus groups is due to the unavailability of some participants from the same category to gather at the same time and in the same place. Even in the smaller groups, interactions between the participants produced deeper discussions, thereby improving understanding [47]. Individual interviews and focus groups were conducted face-to-face by four master’s level research assistants experienced in qualitative research (two with a background in social work, and two in anthropology). One research assistant facilitated the focus group while another took notes. The semi-structured topic guide used by the research assistants was informed by the literature review (including integration dimensions) and discussions across the research team to achieve the objectives of the study. Questions were adapted to the various categories of participants and validated by the research team members, including a patient partner. The Interview Guide is reported in the S1 File. Individual interviews and focus groups were recorded and transcribed verbatim. Excerpts were anonymized.

Table 1

Characteristics of the participants (n = 129).

Participants	Patients		Health professionals	Managers
Type of interview: n
Individual interviews	25		20	13
Focus groups	0		9	4
Total of participants: n	25		69	35
Variables
Gender: n (%)		Gender: n (%)
Female	12 (48%)	Female	47 (68%)	26 (74%)
Male	13 (52%)	Male	22 (32%)	7 (20%)
Age (years): n (%)		Years of experience: (x̄)	12	7
18–40	3 (13%)	Profession: n (%)
41–64	10 (33%)	Family physicians	32 (46%)
65+	12 (50%)	Primary care nurses	3 (<4%)
Educational level: n (%)		Pharmacists	9 (13%)
None	1 (4%)	Community representatives	25 (36%)
Primary	7 (29%)
Secondary	15 (58%)
College	1 (4%)
University	0 (0%)
Occupation: n (%)
Full-time/part-time work	3 (13%)
Full-time school	1 (4%)
Unable to work due to health condition	9 (33%)
Retired	10 (42%)
Married	11 (46%)
Single	8 (33%)
Divorced/separated	4 (13%)
Widowed	1 (4%)
Income (CAN$): n (%)
$0–$20,000	15 (58%)
$20,000–$40,000	5 (21%)
$40,000-$60,000	1 (4%)
$60,000–$100,000	1 (4%)

Credibility (accurate description of the phenomenon) was ensured by asking open-ended questions, by allowing participants some latitude in what they wished to reveal and by the triangulation of informants. Data saturation was not targeted for each of the participant categories, but the diversity of the actors involved (triangulation) allowed for a comprehensive representation of the phenomenon and enhanced trustworthiness [41, 48].

Analysis

Experiences and opinions collected from the participants were analysed according to a mixed thematic analysis [49]. Consistent with the descriptive design, this approach helps to identify “codes” or labels that assign symbolic meaning to the raw descriptive information compiled during the study [49]. Four research team members took part in the analysis process according to three iterative stages allowing data-driven coding and categorization to identify emergent themes and trends: data condensation, data organisation and their interpretation [49]. First, data were categorized in themes identified according to Valentijn et al.’s taxonomy and conceptual framework [36, 37] (deductive) and other relevant information allowing us to achieve the research objectives (inductive). This step of data condensation was processed using NVivo software (Version 11). Second, tables were created to organise and synthesize the data, grouping them into a smaller number of themes (data organisation). Third, patterns were identified, described, and explained (interpretation). Three members of the research team validated each step of the thematic analysis process according to the investigator triangulation method [50].

This study received approval from the Ethics Review Boards of the Saguenay-Lac-Saint-Jean Integrated University Health and Social Services Centres. All informed consent was given in writing.

Results

Table 2 summarizes the results presented in the following section.

Table 2

Strategies, enablers, and barriers for community stakeholders’ engagement in CMPs according to the Rainbow Model of Integrated Care.

Integration dimensions	Engagement strategies	Engagement enablers	Engagement barriers
ClinicalCoordination of person-focused care in a single process across time, place and discipline	Use of the individualized service planCare coordination by the case managerPerson-focused intervention	Patients’ involvementGlobal understanding of the patientMutual understanding of rolesComplementarity of health care and community resources	-
ProfessionalInter-professional partnerships	Use of the individualized service planInter-professional collaboration	Shared vision, collaboration, and consensus among providersInterdependence between hospital and community stakeholdersLess services duplicationLess contradictions in care planning	Lack of recognition of CBOs by certain hospital providersTime required to participate in an individualized service plan
OrganizationalInter-organizational partnerships	Formal consultation mechanisms between hospital and CBOsInter-organizational collaborationDecision makers and managers support	Knowledge of each other organizations involved in the programConcerted efforts	Lack of opportunities for community stakeholders to be involved in decision-making processes within CMPs
SystemicPolicy arrangements	-	-	-
FunctionalSupport mechanisms and communication tools	Financial, managerial, and informational supportFormal communication channels between the hospital and community stakeholders	Access to the patient’s informationStaff stabilityPrevious collaboration established between the case manager and community stakeholders	Different opening hours from one organization to another
NormativeCultural frame of reference mutually respected by all	Use of the individualized service plan	Individual openness to collaborationCommon purpose towards frequent users of health services	Cultural differences in focus on physical vs psychosocial healthDifferences in bureaucratic structures and funding mechanisms

Clinical integration

Participants recognized the usefulness of the individualized service plan as a powerful tool to ensure a global understanding of the people’s situation, focusing on their priorities and enabling the complementarity of health care and psychosocial resources.

“Sometimes the individualized service plan is where you can really get to know the person a little more as a whole.” (Focus group with CBO representatives)

“Involving them [people with complex needs] as well as making them responsible for the overuse of services; whether by having them attend the individualized service plan meeting, or other such individualized references, I believe is empowering for these people.” (Focus group with CBO representatives)

“We developed an individualized service plan so that all the stakeholders on both the social and physical sides understand the consequences of my health problems and treatment… I can explain my background. I know my situation very well.” (Individual interview with a patient)

The difficulty for CBOs to help people with physical pain was also mentioned and calls for collaboration between healthcare services, illustrating the complementarity of healthcare and community resources.

The important role of case managers in care coordination across services at the clinical level has also been raised by a participant.

“It definitely takes a conductor for this global coordination. The case manager is like the orchestra’s conductor.” (Individual interview with a family physician)

Community stakeholders and hospital providers both recognized and adopted the person-focused approach, which improves clinical integration and may enable collaboration and engagement between stakeholders.

“The minute you hear the words ‘vulnerable clientele’ […] It means … these people have special needs, and someone has to take care of them, no matter who. It may be a team, an individual, several people, a community, a society, a family, whatever […] together with the client, with his or her experience, we will take him or her elsewhere.” (Individual interview with a hospital manager)

“You don’t have to work for the system, to unclog the system, you have to work for the person. If you focus on that, maybe the solutions will be easier than passing the buck.” (Focus group with CBO representatives)

Professional integration

Two main processes related to professional integration were described by participants: having a shared vision between providers focusing on the content of care and the development of an interdependence between hospital providers and community stakeholders. Again, the individualized service plan was outlined as an important tool to foster a shared vision, enabling consensus among stakeholders and reducing duplication of services. Community stakeholders recognized the added value of the collaboration. Providers from the hospital and community stakeholders also recognized that individualized service plans support the development of collaboration with CBOs.

“Everyone is on the same page, everyone has a defined role, rather than sometimes duplicating services or contradicting each other. People cannot always come together, which is what individualized service plans allow them to do.” (Focus group with CBO representatives)

“We are all here to discuss the same patient. It’s amazing how together we make a much greater difference than each of us on their own.” (Individual interview with a community pharmacist)

However, a condescending attitude toward and lack of recognition of CBOs by certain hospital providers and the time required to participate in an individualized service plan were outlined as barriers to professional integration.

“In terms of personality, there are some who will come to us and impose themselves as experts. ‘Look here, I’ve been doing this for 25 years…’ But not everyone is like that. There are others who arrive a little awkwardly, they are great to deal with. So that’s it, there is also a lot of whoever you have in front of you.” (Focus group with CBO representatives)

“There is a lack of knowledge about the existence of community services, but once you know about them, you have to recognize the professional expertise within the community network […].” (Focus group with CBO representatives)

“I mean, it’s a barrier that we have to take the time, in community pharmacies, to participate in an individualized service plan. It’s a major financial hurdle […].” (Individual interview with a community pharmacist)

Organisational integration

Organisational integration between healthcare services and community stakeholders in CMPs happened mainly through knowledge of each other and through concerted efforts between these organisations.

“Of course, it requires a concerted effort, but the providers also need to know about the organisations’ services, departments, and missions, whether through us or others. For example, for a patient who never comes to his appointments, because he has atypical hours, he sleeps during the day, there is street work, there are outreach services and community organisations that work at atypical hours, which could help us to remedy the situation as well as taking part in the individualized service plan.” (Focus group with CBO representatives)

“All these organisations [CBOs] are often useful for respite. And, often, when people live in isolation, if they don’t know what to do, they come to the emergency department or their level of distress rises quickly. I believe that these organisations do have a complementary role.” (Focus group with hospital managers)

“I just wanted to add that there are a lot of community organisations in our mental health individualized service plans […] There is a great collaboration. […]

I’ve been the coordinator since 2008, and it’s amazing how much better our relationship with the community network gets every year.” (Focus group with a coordinator and a case manager)

Lack of opportunities for CBOs and community pharmacies to be involved in decision-making processes within CMPs for people with complex care needs was reported as a significant barrier to their engagement. As suggested by some participants, CBOs and community pharmacies should be more involved in decision-making about these programs and especially about the way patients can be identified and supported. Formal consultation mechanisms between the hospital and CBOs were suggested to overcome this barrier.

“[…] could a complex case committee not be set up, with the [health] network and with community organisations, so that we can work in collaboration rather than just one way.” (Focus group with CBO representatives)

System integration

No direct processes concerning system integration were identified from the participants’ narratives.

Functional integration

Information management and resource management were the only two functional integration- processes described by the participants. Knowledge of the individualized service plan by CBO representatives and pharmacists provides an overview of the patient’s situation, so they can refer the patient or intervene more efficiently. For their part, patients do not have to repeat their stories to every care team member. Some other communication channels between the hospital and community stakeholders were recognized as promoting better access to the patient’s information and to common knowledge that facilitates clinical, professional and organisational integration.

However, most of these communication channels relied on previous collaboration between the case manager and stakeholders involved. These narratives illustrate how both information management and resource management can influence functional integration and may demobilize stakeholders.

“When we know people and we have a good relationship, we have the right information. When these people retire, change jobs, or leave the organisation, we lose it […]. It is challenging because there is no established communication structure. There should be clear channels of communication and staff management that improve staff stability, but there is nothing, it’s case-by-case. […] The turnover rate means it changes all the time.” (Focus group with CBO representatives)

Normative integration

Cultural differences between hospital and community stakeholders regarding the focus of the intervention (psychosocial vs healthcare needs) and differences in bureaucratic structures and funding mechanisms may affect community stakeholders’ engagement.

“I would tell you that, with the hospital, of course, we have to work together anyway, the partnership is still going well, but we have to work on it. Because, in fact, it’s two different cultures, the way of doing things is different too. Of course, there is dissatisfaction in the way of doing things.” (Focus group with CBO representatives)

“There is a reality with regard to CBOs, which is that they are autonomous, they can do what they want, and then the funding, which is related to this among other things, means that, theoretically, we are not required to have relationships. Therefore, it depends more on the goodwill of the people who work there.” (Focus group with CBOs representatives)

Despite these differences, the organization of individualized service plans can help stakeholders focus on a common purpose for frequent users of health services.

“What we often realize in the individualized service plans is that we worked in different ways, in different directions, and the person was quite happy with that. Now, when we all go the same way, it’s much simpler. The person is well supported, and we know where we are going. It works, it works.” (Focus group with CBO representatives)

Discussion

There is growing recognition that integrating care can improve patients’ outcomes, especially among those with complex health and social needs [25]. By ensuring communication and collaboration between professionals of various organisations, and the participation of every stakeholder, case managers are “searching for connections between the healthcare system and other human service systems to improve outcomes”, which correspond precisely to the definition of integrated care as stated by Leutz [10]. Previous studies showed that promoting interorganizational collaboration faces a greater challenge than promoting interprofessional collaboration due to differences between corporate cultures, geographical distance, the multitude of processes, and formal paths of communication [51]. The results of this study confirm the gap between community stakeholders and CMPs due to these challenges and offer new insights into this engagement.

CBOs and community pharmacies wish to be engaged in CMPs. Their proximity to the population (physical presence in the living environment), their adaptability and plurality of service delivery, their knowledge of the daily users’ situation and individual needs and goals, and their complementary knowledge, whether about pharmaceutical or psychosocial aspects can contribute significantly to improving the programs [52-55]. CBO and pharmacy stakeholders are also well positioned to help identifying people with complex care needs.

For community stakeholders, the individualized service plan remain the main ingredient of the CMP. The use of a multidisciplinary/interorganisational care plan is already recognized as an effective approach to aligning the goals of the different healthcare services and as an effective strategy to ensure positive program outcomes for people with complex health and social needs [56-58]. Community stakeholders believe that they can and should contribute to the individualized service plan. According to them, this contribution could improve global patient engagement, better access to patient information and interprofessional collaboration. However, cultural differences, as well as challenges in communication channels were raised as significant barriers to this contribution, as collaboration still often relies on a history of collaboration between involved parties [26, 37, 55, 59].

In response to these challenges, many participants outlined, as suggested by other authors [60], the importance of formalizing partnerships and communication channels. These improvements should span “over the full continuum of services as opposed to separate providers and sectors” [61], building on but going beyond previous collaborations. As observed by Fleury et al. (2014), a vulnerable population with complex needs evolving in a decentralized network needs more formal partnerships to improve the integration of services [62]. As one research participant mentioned, “Collaboration must become the norm”. Hospital decisions should consider the inclusion of community stakeholders on CMP governance committees. To do this, community-based and person-focused paradigms of care must be strengthened [63] and community stakeholders must be considered as co-producers of care [64] and, ultimately, as co-builders of social policies [21] for people with complex needs. Decision makers must consider adequate funding [60] dedicated to community stakeholders participation in individualized service plans [65, 66] and their engagement in CMPs. In the same way, the programs need to be supported and pursued in a perspective of ongoing improvement.

Limitations of the study

The community stakeholders who participated in the interviews and focus groups did not all have direct exposure to the CMPs. Their variable experiences within the programs may have influenced the results. However, all community stakeholders were referred to the research team by a case manager, worked with the targeted clientele, had connections with the health and social services network and had a minimum of knowledge about the programs. Their contribution was still relevant to the study.

As mentioned, the Interview Guide was not formatted based on the Rainbow Model of Integrated Care. Although it is a robust framework, elaborated to provide all stakeholders’ perspectives at all levels (macro, meso and micro) and internationally recognized in the field of integrated care, it remains difficult to use in the way it is formulated. For example, no system integration processes were identified from the participants’ narratives, but this type of integration can be difficult to differentiate from organisational integration and may be less relevant to clinical stakeholders [36, 38].

Finally, the limited description of the settings where CMPs were implemented makes the transferability of the results difficult. However, the heterogeneity of the contexts (i.e. populations served by CMPs, their urban and rural environments, their size, the types of providers who participated) may increase the theoretical transferability.

Conclusion

While CMPs remain powerful tools for integrated care for people with complex needs, there is a persistent gap when it comes to fully engaging community stakeholders in case finding, as well as development and implementation of the individualized services plan. Formalized strategies to promote partnerships and better communication channels are needed, as well as the involvement of these stakeholders on governance committees at the healthcare system level.

Interview guide.

(DOC)

Click here for additional data file.

(DOCX)

Click here for additional data file.

5 Jul 2021

PONE-D-21-11296

Case management programs for people with complex needs: towards better engagement of community pharmacies and community-based organisations.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: No

Reviewer #3: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this paper that reports on interviews and focus groups to explore the roles of community pharmacies and community-based organisations in the case management of patients with complex needs. This topic is relevant to an international audience considering the growing numbers of people with multiple co-morbidities and complex needs. The actual systems that are in place in various countries will differ, especially in terms of funding models, however the overall involvement of pharmacies and community support organisations would be relevant internationally.

General feedback

The manuscript is well written and flows well. My main comments relate to the need to incorporate more details in the methods section and the reason for the chosen methodology used for the analysis.

Introduction

The paragraph starting line 99 mentions the lack of knowledge about CBOs. There is literature showing lack of understanding of the role and scope of community pharmacies from consumers as well as health professionals that could be included here.

Minor:

Line 52: delete comma after episodic.

Line 91: this sentence does not read well. Should this be: … complex care needs such as those needing CMPs.?

Material and methods

The authors used descriptive qualitative design and include two references although both > 10 yrs (2000 and 2009). Why was this methodology followed? Reading the manuscript the process followed seemed to be similar to framework analysis. Could the authors add a statement on the chosen methodology?

Why do both focus groups and interviews? An explanation as to the reasoning behind using both would be useful.

Table 1 provides demographic details of patients however there is no details of the health professionals and managers in terms of years of practice experience and working in their various roles.

Minor: write out numbers <10

Results

More details are needed:

• When were the focus groups and interviews conducted?

• Who conducted the interviews and who facilitated the focus groups? Did the researcher have the appropriate skills?

• How long were interviews and focus groups (mean/median, min max)

• Were all interviews face-to-face?

• How was the interview tool developed and validated (face and content validation)?

Considering the number of interviews and focus groups conducted, I wanted to see more quotes to support the interpretation. I assume the interviews would have provided a wealth of data however only a few quotes are included to support the interpretation.

Discussion

The last sentence of the first paragraph: is there a gap between CBOs and community pharmacies or rather between these stakeholders and CMPs?

Reviewer #2: The aims of this studied were 1) to describe how case management programs engaged community pharmacies and community-based organisations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement. However, there are no evidences derived from the scientific and statistical analyze in this study. The information of participants’ characteristics is lacking (e.g. comorbidity, reason for visiting to the emergency department or hospitalizations, drug history). What types of disease improved by using this program?

In addition, the authors should show the evidence of improving patients’ outcome. Did the number of hospitalization reduce by this program? How about the number of visiting to the emergency department? The study design is not sufficient to sustain the claims of the authors.

Reviewer #3: Summary of the research: This manuscript was a qualitative study examining how case management programs can better bridge/engage CBOs and community pharmacies to the health care system. The Taxonomy of Integrated Care was used to analyze the results. The results illustrate how different stakeholders view CMPs, CBOs, community pharmacies, etc., as well as the various components and stakeholders involved. Upon first read, I had a very difficult time following this paper and how the objective, conceptual model, methods, and results all tied together. Therefore, I would recommend substantial revisions to help enhance the clarity of this work.

Major issues:

1. In the introduction, with so many different players (CBOs, CMPs, community pharmacies, hospitals, clinics) that is was difficult to keep track of how they all tied together. It may help clarify this if there could be a figure of some sort. For example, CBOs and community pharmacies on one side, other stakeholder on the other, and CMPs forming a bridge between the two. Or CMPs serving as some type of umbrella. As it is now, it was not immediately apparent how all these pieces function in an ideal setting.

2. I was unfamiliar with the conceptual model. I think it could benefit from a sentence or two describing why that model was selected and how the model was developed. I think most readers will also be unfamiliar with the Rainbow Model of Integrated Care, so that requires a brief explanation. I also wonder if it would be more clearly described in a table where one column has the care processes and the second column has a description. This would make it easier to read and follow.

3. Why were both interview and focus groups carried out? This should be justified for the reader. Also, focus group size varied widely, what was the rationale for determining focus group size? Were focus group best practices followed? I think far more description of the methods is needed such as how participants were identified, how they were solicited to participate, their previous experience with CMPs, etc.

4. Analysis: I thought this work was guided by the Taxonomy for Integrated Care? Please clarify. I also think that more detail of the data analysis is needed. For example, can you describe in more detail what happened in each of the three stages? In addition, what is meant by cross-validation? Was there interrater reliability? Peer review? Member checking? I think more description is needed of how validity was maximized.

5. I found the results quite hard to follow. It may be better here to describe what each integration component means and how it appeared in the results of this study. Currently, the reader has to scroll between the conceptual model section and the results section to understand what each heading means. I also think it would benefit from more description (in other words, if all the quotes were removed, I think there should be adequate descriptions of each theme so that the reader understands how they presented in the results)

6. In the limitations, if participants had varying exposure to CMPs, it may have been helpful to organize the focus groups according to their exposure. For example, put all of those with high exposure in to the same groups and all of those with low exposure into the same groups. Since the authors state in the limitations that the Rainbow Model is difficult to use, there needs to be more justification for why it was selected.

7. It is difficult to understand how the results link to the objectives. It may be better to frame the results in terms of engagement strategies, engagement barriers, and engagement enablers to better answer the objective than group the results using the Rainbow Model. Alternatively, these engagement pieces can more clearly be described within each Rainbow Model component.

8. The objectives seem somewhat distinct. For example, at first why patients and physicians were being interviewed as they don't seem to be needed to address the first objective. Therefore, if the intent is to answer objective one, then it may be necessary to exclude data from patients, nurses, physicians.

Minor issues:

1. In the introduction, I would define CMPs similar to how you define integrated care

2. I would suggest consulting with a pharmacist on how to describe community pharmacy services as I am not sure what is meant by "file analysis"

3. There were a lot of acronyms making it hard to keep track of what they stood for. I would suggest writing more of them out.

4. What is a "descriptive qualitative design"? I would suggest describing this to the reader

5. p. 9 line 168 – what stakeholders were typically involved in the meeting?

6. I think including an interview guide would be helpful as the broad interview topics that are provided in the appendix to not give much insight on what was discussed.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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24 Sep 2021

JOURNAL REQUIREMENTS

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: We standardized the manuscript (file naming and headings) according to PLOS ONE’s style requirements.

2. When reporting the results of qualitative research, we suggest consulting the COREQ guidelines or other relevant checklists listed by the Equator Network, such as the SRQR, to ensure complete reporting (http://journals.plos.org/plosone/s/submission-guidelines#loc-qualitative-research). In this case, please consider including more information on the number of interviewers, their training and characteristics; on how interviews and focus groups were conducted, and on participants selection and recruitment. Moreover, please provide the interview guide used as a Supplementary file

Response: Following the SRQR Checklist (https://www.equator-network.org/reporting-guidelines/srqr/), we added all the required information about the methods, especially the data collection (pages 10-11, lines 196-213, 220-235). We also included the Interview Guide and the completed SRQR Checklist as supplementary files.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Response: We added information about ethical or legal restrictions on sharing our de-identified data set in the revised cover letter.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response: We included the captions at the end of the manuscript.

REVIEW COMMENTS TO THE AUTHOR

Reviewer #1

Comment: Thank you for the opportunity to review this paper that reports on interviews and focus groups to explore the roles of community pharmacies and community-based organisations in the case management of patients with complex needs. This topic is relevant to an international audience considering the growing numbers of people with multiple co-morbidities and complex needs. The actual systems that are in place in various countries will differ, especially in terms of funding models, however the overall involvement of pharmacies and community support organisations would be relevant internationally.

Response: Thank you for this positive comment.

General feedback

Comment: The manuscript is well written and flows well. My main comments relate to the need to incorporate more details in the methods section and the reason for the chosen methodology used for the analysis.

Response: We added more information in the Methods section to further describe and explain the methodological choices (pages 9-13, lines 162-165, 185-186, 196-213, 220-235, 248-250, 252-263).

Introduction

Comment: The paragraph starting line 99 mentions the lack of knowledge about CBOs. There is literature showing lack of understanding of the role and scope of community pharmacies from consumers as well as health professionals that could be included here.

Response: We added a statement and a reference to this effect (page 6, line 109).

Minor

Comment: Line 52: delete comma after episodic.

Response: We made the change (page 4, line 54).

Comment: Line 91: this sentence does not read well. Should this be: … complex care needs such as those needing CMPs.?

Response: We moved "such as CMPs" earlier in the sentence to clarify its meaning (page 5; line 94).

Material and methods

Comment: The authors used descriptive qualitative design and include two references although both > 10 yrs (2000 and 2009). Why was this methodology followed?

Response: We already explained the use of this approach (page 8; lines 161-163). However, we replaced the references with more recent ones, and we added an additional explanation for the rationale (page 8-9; lines 163-165).

Comment: Reading the manuscript, the process followed seemed to be similar to framework analysis. Could the authors add a statement on the chosen methodology?

Response: The framework analysis method sits within a broad family of qualitative analysis methods, as does the thematic analysis. Although this method might have been relevant, it can be time-consuming and holds the potential for researchers to move away from the raw data (Ward DJ, Furber C, Tierney S, Swallow V. Using Framework Analysis in nursing research: a worked example. J Adv Nurs. 2013 Nov;69(11):2423-31). We added a statement about the chosen methodology in the Analysis section (page 13, lines 248-250).

Comment: Why do both focus groups and interviews? An explanation as to the reasoning behind using both would be useful.

Response: We added a brief explanation (pages 10-11, lines 208-213).

Comment: Table 1 provides demographic details of patients however there is no details of the health professionals and managers in terms of years of practice experience and working in their various roles.

Response: Unfortunately, we did not collect these data.

Comment: Minor: write out numbers <10

Response: We made the modifications (pages 9, 11, lines 175, 218).

Results

More details are needed:

Comment: When were the focus groups and interviews conducted?

Response: We added this information (page 10, line 197).

Comment: Who conducted the interviews and who facilitated the focus groups? Did the researcher have the appropriate skills?

Response: We specified this information (page 11, lines 227-229).

Comment: How long were interviews and focus groups (mean/median, min-max)

Response: The interviews lasted one hour. We added the duration of the focus groups, i.e. between 45 and 90 minutes (page 11, lines 216-217).

Comment: Were all interviews face-to-face?

Response: Yes, all interviews were face-to-face (page 11, line 227)

Comment: How was the interview tool developed and validated (face and content validation)?

Response: We added this information (page 11; line 229-233).

Comment: Considering the number of interviews and focus groups conducted, I wanted to see more quotes to support the interpretation. I assume the interviews would have provided a wealth of data however only a few quotes are included to support the interpretation.

Response: Indeed, a lot of data was collected with interviews and focus groups. We have voluntarily chosen to limit the number of quotations to leave more room for the text. However, we added more quotations to enrich the interpretation and to enhance the message (page 18, lines 300-308; page 21, lines 370-372; page 23, lines 429-433).

Discussion

Comment: The last sentence of the first paragraph: is there a gap between CBOs and community pharmacies or rather between these stakeholders and CMPs?

Response: We modified the sentence to explain that there is a gap between stakeholders and CMPs (page 24, line 445).

Reviewer #2

Comment: The aims of this studied were 1) to describe how case management programs engaged community pharmacies and community-based organisations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement. However, there are no evidence derived from the scientific and statistical analysis in this study.

Response: In qualitative research, there is no statistical analysis. The scientific literature on similar topics used similar methods and provided results comparable to ours. We used methods of qualitative data collection (individual interviews and focus groups) and qualitative data analysis (thematic analysis) largely recognized and validated in qualitative research.

Comment: The information of participants’ characteristics is lacking (e.g. comorbidity, reason for visiting the emergency department or hospitalizations, drug history). What types of diseases improved by using this program? In addition, the authors should show evidence of improving patients’ outcomes. Did the number of hospitalizations reduce by this program? How about the number of visits to the emergency department? The study design is not sufficient to sustain the claims of the authors.

Response: As already mentioned, the objectives of the study were 1) to describe how case management programs engaged community pharmacies and community-based organizations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement. We did not aim to describe the characteristics of frequent users recruited in CMPs, neither to assess the impact of the CMPs on the patients’ health status or health service utilization. These outcomes are available in other studies mentioned in the introduction (page 4; lines 60 and 65).

Reviewer #3

Comment: Summary of the research: This manuscript was a qualitative study examining how case management programs can better bridge/engage CBOs and community pharmacies to the health care system. The Taxonomy of Integrated Care was used to analyze the results. The results illustrate how different stakeholders view CMPs, CBOs, community pharmacies, etc., as well as the various components and stakeholders involved. Upon first read, I had a very difficult time following this paper and how the objective, conceptual model, methods, and results all tied together. Therefore, I would recommend substantial revisions to help enhance the clarity of this work.

Response: Thank you for your comment. We made significant modifications to the manuscript to improve its readability and to clarify the concordance between the objectives, the conceptual model, the methods, and the results.

Major issues:

Comment: 1. In the introduction, with so many different players (CBOs, CMPs, community pharmacies, hospitals, clinics) that it was difficult to keep track of how they all tied together. It may help clarify this if there could be a figure of some sort. For example, CBOs and community pharmacies on one side, other stakeholders on the other, and CMPs forming a bridge between the two. Or CMPs serving as some type of umbrella. As it is now, it was not immediately apparent how all these pieces function in an ideal setting.

Response: Indeed, CMPs involve many actors with different roles and it is easy to get lost. We added Figure 1, entitled “Relationships between stakeholders engaged in CMPs”, as you suggested (page 6, line 104).

Comment: 2. I was unfamiliar with the conceptual model. I think it could benefit from a sentence or two describing why that model was selected and how the model was developed. I think most readers will also be unfamiliar with the Rainbow Model of Integrated Care, so that requires a brief explanation. I also wonder if it would be more clearly described in a table where one column has the care processes and the second column has a description. This would make it easier to read and follow.

Response: We agree that the conceptual framework may be difficult to understand in the current version and would need more explanation. To clarify, we added more details about the Rainbow Model of Integrated Care (RMIC) and its associated taxonomy, we described briefly the methods used for its development and we explained the choice of this model (page 7, lines 127-136). Rather than add a new table on the integration dimensions with each description, we prefer to refer the reader to the article by Valentijn et al. (2013), which includes a table with this information. However, we have included short definitions of the dimensions in the new Table 2, entitled “Strategies, enablers, and barriers for community stakeholders’ engagement in CMPs according to the Rainbow Model of Integrated Care” (pages 15-16), which we have added to the results section following your comments.

Comment: 3. Why were both interviews and focus groups carried out? This should be justified for the reader.

Response: We added an explanation for the use of both individual interviews and focus groups (pages 10-11, lines 208-213).

Comment: Also, focus group size varied widely, what was the rationale for determining focus group size? Were focus group best practices followed?

Response: We added a statement to justify the variation in the size of focus groups (page 11; lines 220-226). We also added information related to focus group best practices (pages 11-12; lines 227-235).

Comment: I think far more description of the methods is needed such as how participants were identified, how they were solicited to participate, their previous experience with CMPs, etc.

Response: We added more details on the data collection (page 10, lines 196-206). However, we cannot provide a description of the participants’ previous experience of the program because this information was not collected.

Comment: 4. Analysis: I thought this work was guided by the Taxonomy for Integrated Care? Please clarify.

Response: As mentioned in the Conceptual framework section, both taxonomy and conceptual framework (Rainbow Model of Integrated Care) were used. We clarify it in the Analysis section (pages 13, lines 252-254).

Comment: I also think that more detail of the data analysis is needed. For example, can you describe in more detail what happened in each of the three stages?

Response: We added a more detailed description of the three stages in the Analysis section (page 15, lines 252-259).

Comment: In addition, what is meant by cross-validation? Was there interrater reliability? Peer review? Member checking? I think more description is needed of how validity was maximized.

Response: We replaced “cross-validation” with “investigator triangulation” (page 13; line 259), a notion that is more appropriate because it involves the participation of two or more researchers in the analysis processes to provide multiple observations and conclusions.

Comment: 5. I found the results quite hard to follow. It may be better here to describe what each integration component means and how it appeared in the results of this study. Currently, the reader has to scroll between the conceptual model section and the results section to understand what each heading means. I also think it would benefit from more description (in other words, if all the quotes were removed, I think there should be adequate descriptions of each theme so that the reader understands how they presented in the results)

Response: We developed a new table to present the results in a clearer and summarized form. Table 2, entitled “Strategies, barriers, and facilitators for community stakeholders’ engagement in CMPs according to the Rainbow Model of Integrated Care” (pages 15-16), aims to clarify the strategies, barriers, and enablers according to each integration dimension of the conceptual framework. We included short definitions of these dimensions in the left column.

Comment: 6. In the limitations, if participants had varying exposure to CMPs, it may have been helpful to organize the focus groups according to their exposure. For example, put all of those with high exposure into the same groups and all of those with low exposure into the same groups.

Response: This is a good point. However, it was difficult to put stakeholders with the same level of exposure in the same groups because of their limited availability, especially the family physicians and the managers. Furthermore, it was not possible for the research team to know the level of the participants’ exposure to the CMPs before organizing the focus groups. Therefore, we preferred to gather the participants in a more “organic” way, i.e. according to their role and occupation.

Comment: Since the authors state in the limitations that the Rainbow Model is difficult to use, there needs to be more justification for why it was selected.

Response: We added a rationale about the choice of this model in the Conceptual framework section and in the Limitations (page 7, lines 127-136; page 26, lines 489-492).

Comment: 7. It is difficult to understand how the results link to the objectives. It may be better to frame the results in terms of engagement strategies, engagement barriers, and engagement enablers to better answer the objective than group the results using the Rainbow Model. Alternatively, these engagement pieces can more clearly be described within each Rainbow Model component.

Response: As mentioned, we developed Table 2 (page 15-16) to organize more clearly the identified strategies, barriers, and enablers for community stakeholders’ engagement in CMPs. Short definitions can be found under each integration dimension of the conceptual framework.

Comment: 8. The objectives seem somewhat distinct. For example, at first why patients and physicians were being interviewed as they don't seem to be needed to address the first objective. Therefore, if the intent is to answer objective one, then it may be necessary to exclude data from patients, nurses, physicians.

Response: Although the main project interview guide did not include a question specific to Objective 1 of this subproject for patients, nurses and physicians, their transcripts might have contained testimonials about their connections to community agencies and pharmacies related to the CMPs. We then decided to review the transcripts from these participants to ensure that we get the most complete description possible.

Minor issues:

Comment: 1. In the introduction, I would define CMPs similar to how you define integrated care

Response: Even if these two notions can seem similar, case management refers to ‘a collaborative, client-driven process for the provision of quality health and support services through the effective and efficient use of resources’. We added this definition (page 4; lines 60-62) to distinguish CMPs from the definition of ‘integrated care’.

Comment: 2. I would suggest consulting with a pharmacist on how to describe community pharmacy services as I am not sure what is meant by "file analysis"

Response: We changed “file analysis” to “medical information review” to clarify (page 5, line 85).

Comment: 3. There were a lot of acronyms making it hard to keep track of what they stood for. I would suggest writing more of them out.

Response: We have limited the number of acronyms by replacing IUHSSC with 'hospital network' (pages 9, 10, 11, lines 170, 177, 180, 203), HSSC with 'hospital' (pages 9, 10, 18, 19, 21, 22, 23, 25, lines 180, 197, 296, 313, 316, 334, 368, 378, 394, 411, 415, 472), CMPs with 'programs' in some places (pages 6, 7, 9, 21, 25, 26 lines 102, 110, 117, 180, 377, 452, 458, 478, 486) and we spelled out ISP throughout (pages 9, 10, 17, 19, 20, 21, 22, 25, 26, lines 183, 189, 269, 273, 277, 281, 314, 317, 322, 326, 335, 349, 362, 391, 455, 459, 477).

Comment: 4. What is a "descriptive qualitative design"? I would suggest describing this to the reader

Response: We added a statement to further describe this method (page 9; lines 163-165).

Comment: 5. p. 9 line 168 – what stakeholders were typically involved in the meeting?

Response: We added this information (page 9; lines 185-186).

Comment: 6. I think including an interview guide would be helpful as the broad interview topics that are provided in the appendix to not give much insight on what was discussed.

Response: We added the Interview Guide as a supplementary file, grouping the questions by participant category.

Submitted filename: Response to Reviewers_PONE-D-21-11296.docx

Click here for additional data file.

22 Nov 2021

Case management programs for people with complex needs: towards better engagement of community pharmacies and community-based organisations.

PONE-D-21-11296R1

Dear Dr. Chouinard,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #3: No

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Reviewer #3: Yes

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Reviewer #3: No

29 Nov 2021

PONE-D-21-11296R1

Case management programs for people with complex needs: towards better engagement of community pharmacies and community-based organisations.

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