Multidisciplinary team perceptions of the Case/Care Managers' role implementation: a qualitative study.

BACKGROUND AND AIM OF THE WORK: The roles of Case Managers, Care Managers and fledgling Case / Care Managers integrate clinical systems to achieve optimal patient outcomes through the coordinated use of the most appropriate clinical resources. Although the Case and Care Managers roles have been researched, there is still little evidence of the development of the Case / Care Manager in the Italian Healthcare System. Aim of this research is to investigate the perception of healthcare professionals of the implementation of the Case / Care Manager figure and how it operates . RESEARCH DESIGN AND METHODS: The study adopted a qualitative descriptive methodology with a phenomenological approach, using in-depth interviews. Participants (N = 21) were health professionals of multidisciplinary teams from several healthcare contexts in northern and central Italy, in which was activated a Case, Care, or Case / Care Manager role. The study was conducted in December 2020/ January 2021. Results. The themes showed a vision of the Case Manager, even a critical one, as a figure in transformation precisely from Case Management to Case / Care management. The themes underline how the Case / Care Manager represent a facilitator of clinical-therapeutic paths while acting as a reference figure, supporting the patient, his/her family and the multidisciplinary team.
CONCLUSIONS: The results of the study confirm the Case / Care Manager as the health professional who deals with care pathways through an integrated, interdisciplinary and personalized approach, placing the person at the centre and thus overcoming a disease-centered approach.

Introduction

Healthcare systems and services are becoming increasingly complex and diverse; thus, care pathways and models need to be revised to address current and future challenges, through the consolidation of health care organizations into more integrated systems. In this evolving scenario, new professional roles are emerging via the implementation of tailored care models, closest to a person’s needs. This has encouraged new approaches to care to accommodate both the procedural aspect and the attention to the person in organizational healthcare models (1).

The Case Manager is a clinician expert in coordinating care pathways, who takes into account the specific needs of an individual, in a cost-effective way. He therefore carries out a complex integrated health and social assistance intervention that is capable of making a unique contribution to health and social assistance (2). The role of this healthcare professional is focused on “the case” and, at the same time, on assuming the role of patients’ “advocate” and educator, thus allowing, in particular in multi-disciplinary contexts, continuity of care and clear and coherent communication for the patient himself (3). Over the years, Case Managers have increasingly identified which areas of knowledge and activity fall within their specific role (4) and between these stands out the basic assessment of the patient, the economic analysis of the relapses of the pathology presented and its respective use of resources, the development and implementation of guidelines regarding patient care, educational interventions, implementation of disease management programs and outcome assessment (5). In addition to this is the effective management of the care network that is created around the patient (6).

The Care Manager is another advanced role that, while maintaining integration with the socio-health services and the multi-professional sphere, offers the patient the most favorable solutions for his clinical-assistance condition, guiding him/her along the care pathway, with a real mix of skills, and playing a critical and decisive role for the effective functioning of healthcare companies (7). This professional figure possesses a deep knowledge of the functioning of the health system, of the directions of development of the profession and of the skills necessary to exercise good leadership and to support the patient (8).

In fact, the Care Managers are included in the coordination process and help the patient in approaching the health system, while they support the improvement of access to services and manage communication within the patient care team (9). In fact, it is necessary that they have excellent skills in information analysis, control, organization, coordination, problem solving, conflict management, and motivation of colleagues and other team members (10). The support to motivation is therefore a central aspect of the activities of the Care Manager, as it allows obtaining important behavioral variations (11). In fact, helping patients to improve adherence to clinical-care processes is important for achieving results in terms of self-care and achieving this goal may include the management of psychological, social and educational interventions (12). Motivational interview represents one of the tools available to the Care Manager (and also to the Case Manager) for the effective collection of information of patient’s clinical condition, and for increasing the level of trust essential to obtain a change in health behaviors (13). On the other hand, the motivational interview was applied to promote health and prevent disease status in specific areas including: improvement of therapeutic adherence (14), management of reversible cardiovascular risk factors (15), disorders anxiety (16), cancer (17), epilepsy (18), and problems with overweight or obesity (19).

The Case / Care Manager (CCM) combination experiments with an innovative model of managing health, which involves a care process based on coordinated health interventions, of important communication aspects with the patient in the clinical/behavioral field and with a significant impact on the participation of the patient to manage their health (20, 21, 22). An approach of this type, therefore, will tend to a holistic health management, centered and designed on the person, thanks to the intervention and support of a professional (23). This evolution of the Case Manager (and Care too) role can be associated with a degree of professional maturity and the ability to pay attention to care process, on behalf of the health professional that will play this role. In addition, this role will require safeguarding the general purposes of the health system while acting with advocacy, which is the fundamental element across the all the care pathway management.

From the existing literature, however, a gap emerges regarding the implementation of this figure, perhaps due to the scarce presence of a Vision in healthcare organizations, that is, a milieu necessary to support and implement the merger of the two profiles of the Case and the Care Manager. The literature collected on the Case Manager and Case / Care Manager mainly investigated their perceptions of their professional role (20, 22). Since the specific Case Manager activity is carried out within the multidisciplinary team, another gap emerges in the literature regarding the perception of the role and the possible evolution from Case Manager to Case / Care Manager by the other elements of the team.

Therefore, the general purpose of the study is the description and analysis of the perceptions that health professionals, from different healthcare settings and pathways, have of the Case Manager’ role, its specificities and possible role changes.

Specific objectives of the study are related to deepening the representations of professionals regarding:

The possible expressions of the Case Manager role and its possible evolution in the figure of the Case / Care Manager;

The processes that substantiate the possible evolution of the role from Case to Case / Care Manager

The fundamental characteristics of the professional who embodies the role of Case / Care Manager.

Methods

Study design

The study adopted a qualitative descriptive methodology with a phenomenological approach. The phenomenological approach allows exploring the meaning of a lived experience from the person’s perspective (24); therefore, it aims to provide a deeper understanding of the meaning of people’s daily experiences and raise people’s awareness of their lived phenomena too (25).

Study Participants

Participants were recruited with convenience sampling approach, using contacts from post graduate health professions courses, word of mouth, social networks (like LinkedIn) and authors personal contacts acquired during an internship. However, it was attempted to include health professionals who differed in socio-cultural background and years of professional experience, to obtain a broader and varied view of the research topic. Participants meeting the following criteria were recruited:

Health Professionals working in settings where the Case, Care or Case/Care Manager operates and he/she is involved with the multidisciplinary team;

Comprehension and agreement for informed consent.

Exclusion criteria were:

To play a role as Case, Care or Case/Care Manager in healthcare settings;

Medical, Nursing and Health Allied Profession students

Data Collection

In-depth interviews, consisting of six open questions (Table 1), were used to explore participants’ experience of the research topic. The researcher who applies a phenomenological approach to the interview asks the participant to express himself on a theme, maintaining an attitude of neutrality, active listening and without guiding the person. The researchers attended an ad-hoc qualitative interview training, to make the group’s interviewing style homogeneous.

Table 1.

Interview questions

Case Management Dimension	Do you know the Case Manager role and what’s your perception about this role? How do you experience this figure in your work setting? How long you have been working together. From your perspective, what are the advantages to have a Case Manager in your work sector?
Care Management Dimension	From your point of view, in which ways is the Case Manager committed to “personalise” patients care pathway? Can you give us an example? In your opinion, which activities or aspects of Case Manager’s role may belong more to a caring or care field?
Case/ Care Management Dimension	Do you think it is possible to have both aspects of care and case management all expressed in one role? Can you describe how, in which possible ways? In your opinion, can Case/Care Manager role implementation correspond to person-centred care principles and activating persons’ self-care potentials? Do you have any examples or ideas to develop?

Setting

In order to collect the voices of professionals from different settings and roles, hospital and territorial contexts from northern and central Italy were included.

Data analysis

The audio-recorded material was encoded to ensure anonymity and then verbatim transcribed. The textual material was analyzed using a thematic analysis approach. Through the thematic analysis, themes highlighting the essence of the text were developed according to patterns identified by the researchers during the careful and interactive reading of the text (26). The process that leads from the first coding to the identification of the themes requires repeated reading of the texts and comparison in the research team. The themes, with an abstraction, iterative and systematic process, have been refined to define the significant aspects of the phenomenon chosen as the object of research in the most faithful and close way possible to the representations of the participants (26).

Rigor

The analysis process rigor and credibility was guaranteed by following the steps: 1) Verbatim transcriptions of the material collected (audio/video) from the interviews; 2) In an initial phase, the researchers worked in pairs comparing the reading and the initial coding of the material; 3) The preliminary analyzes of the interviews were then shared and discussed by the research group during several inter-analysis meetings and with the presence of the research tutor and co-tutor; 4) At every level of analysis (from the first codifications to the formation of the first themes), there has always been a comparison of the analysis products with the respective significant text units to arrive at a conceptualization that is as faithful as possible to the material textual (27).

Ethical consideration

The study was designed in respect of the Helsinki declaration (www.wma.net). The data were collected with the prior informed consent of the interviewees and in respect of privacy and confidentiality. All participants before the interview signed the informed consent. In submitting informed consent, the modalities of the study and the methods of conduct were verbally explained. Each subject was free to give up or withdraw at any time without having to provide any explanation and without this decision affecting his professional life. The data have been processed and stored in compliance with the rules of the University GDPR.

Results

Twenty-one (N=21) interviews were conducted during December 2020 / January 2021. Participants belonged to four different health contexts, three hospitals and one territorial, based in northern and central Italy, and specifically from six different clinical areas (shown in table 2).

Table 2.

Participants’ demographic characteristics (N=21)

Criterion	Sub-Criterion	Mean (SD) ; range
Age		44,3 (12,13); 25-70
Work experience		15 (8,3); 3-30
		N (%)
Gender	Male	5 (24)
	Female	16 (76)
Department	Primary Care/Outpatients unit	5 (24)
	Breast Unit	4 (19)
	Rehabilitation Dept.	4 (19)
	Medical Discharge Unit	3 (14)
	Emergency Dept.	3 (14)
	Stroke Unit	2 (9,5)
Profession	Physiotherapist	3 (14)
	Social Worker	3 (14)
	Surgeon (Breast Unit)	2 (9,5)
	District Nurse	2 (9,5)
	Surgeon (A&E)	1 (4,8)
	Orthopedic Specialist	1 (4,8)
	Physiatrist	1 (4,8)
	Nurse Manager	1 (4,8)
	Neurologist	1 (4,8)
	Speech Therapist	1 (4,8)
	Occupational Therapist	1 (4,8)
	Psychologist	1 (4,8)
	Physician	1 (4,8)
	Oncologist	1 (4,8)
	Physiotherapist Coordinator	1 (4,8)

The interviews lasted a maximum of 30 minutes, the variability of duration depended not only on time/work factors but above all on the willingness of the various health professionals to deepen and explore the proposed topic. The interviews were carried out both face to face (n = 10) and online (n = 11), to meet the logistical difficulties and those related to the Covid-19 pandemic. All interviews were audio/video recorded.

The thematic analysis brought to light three main themes: Care continuity; Case Manager as an intra-interdisciplinary intermediary; From Case Management to Case / Care management (Table 3).

Table 3.

Themes and Subthemes

Themes	Sub-themes
Continuity of Care	The intra-hospital continuity Post discharge continuity on the territory Responsibility of care pathway and person empowerment
Case Manager as Intra- Interprofessional intermediary	Responsibility of the dialogic process Reduction of management issues
Towards the Case/Care Management	Being in touch with patients and their families. Case/Care Management auspicable implementation in healthcare settings; Integration and value of skills: the evolution of the concept of Case / Care Management. The Lack of time: “criticality” for the role

An emerging theme highlighted by the analysis was the continuity of care. The ongoing relationship between those who provide and those who receive a health service is one of the determining factors in defining the quality of care. It is essential to lead the person into the potential labyrinth represented by the health services system, and guide him/her toward the most effective and appropriate care pathways to meet their expressed and unexpressed needs. This theme summarizes the positions and perceptions of the participants regarding the management of patients care pathway by the entire healthcare network present in the hospital and the territory. The issue of continuity of care perfectly enhances the figure of the Case Manager as an essential strategy in improving the quality of care and as an effective response to critical problems, organizational complexities and human difficulties posed, in particular, by fragile patients, who require time of meaningful care.

“Thanks to the collaboration and interaction with the case managers of the discharge center of the hospital, today, we can focus our attention on various health aspects, not only clinical, but also social-assistance, and this is fundamental for the development of an effective clinical pathway for the patient, useful for avoiding unnecessary further hospitalizations” Physician (cod. 3, 15)

The subthemes identified were: (i) The intra-hospital continuity; (ii) Post-discharge continuity on the territory; (iii) Responsibility of care pathway and person empowerment.

(i) The intra-hospital continuity. Intra-hospital communication between the person and professionals, for any care setting, is the essential tool for dealing with complex technical, organizational, human and relational situations. The Case Manager, as a constant figure in daily care, is in possession of an effective intra-hospital communication, a relational modality calibrated on the person who validates the treatment path, reaching a standard of appropriateness and clinical quality of assistance.

“It is certainly an optimal way [the Case management] because it ensures that there is continuity within the dynamics of the department.” Neurologist (cod. 7, 4)

“So, how to say? It is important because it is a figure [Casemanager] (…) who brings together the various aspects and needs of the person (…) in this sense. Because it has a continuity with the cases too (…) it happens in some departments where perhaps the medical team may change” Social worker (cod. 10, 13)

(ii) Post-discharge continuity on the territory. The hospital-territory continuity represents the fundamental combination of healthcare, establishing a reference care service made up of a multi-professional team, which guarantee a multidimensional approach. The Case Manager is perceived, and identified, as a connection between the out-of-hospital services, with the task of planning specific paths for complex health management. The protagonist of these services are fragile patients with chronic pathology, with high care needs and / or with poor social support.

“Compliance also increases. So, the fact that patients felt that is followed, and not just seen once by the team and then abandoned, improved both the relationship and the clinical situation. So, they [Casemanager] should be placed, within the territorial reality, as a central figure, therefore as a pivot for taking charge of the situation in the hospitals and the home care center” Physician (cod. 3, 4)

“For us, the case manager is a reference figure (...) he is the one who has the patient’s situation under hand, both from a clinical point of view and from the patient’s frame. From when the patient enters to when leaves, then the discharge or the transfer (...). “ Physiotherapist (cod.18, 10)

(iii) Responsibility of care pathway and person empowerment.

The Case Manager has the task of coordinating and monitoring planned care for patients who need to access services in a timely manner, preserving the person’s best interest and the sustainability of the health system. The management of the care plan also requires the ability to facilitate communication and the ability to make decisions, taking into account the complexity of the person and enacting patients’ empowerment.

“Transform the person; empower them, with greater collaboration in his care (…). She is able to detect the patient’s subjectivity and therefore can improve the completely emotional impact (…) this is a unique thing that the Case Manager does “Psychologist (cod. 10, 3)

Case Manager as Intra-Interprofessional intermediary. The Case Manager takes charge of the patient and his family adopting more or less complex care paths; thus, he/she coordinates various professionals and resources, guaranteeing personalized assistance and favoring the logic of teamwork and care planning in terms of quality.

“These new figures (CM) are truly the litmus test of the quality of a multidisciplinary work. Because by now both the diagnostics and the treatments have become so complex and articulate that there is an absolute need for someone to keep the ranks, to accompany the patient from the various figures and therefore be the real director. “Oncologist (cod. 12, 7)

“Case Manager as important feedback on the patient’s therapeutic progress, as a glue figure between all the professionals who revolve around the patient ... the case manager helped me to get in touch with other figures such as the speech therapist, with the physiotherapist, to have an overview and encourage team work “ Occupational Therapist (cod. 6, 8)

The subthemes identified were (i) responsibility of the dialogic process and (ii) reduction of management issues.

(i) Responsibility of the dialogic process. The Case Manager facilitates interactions between the team members involved in the clinical care path and the family, stimulating a constructive discussion, the expression of emotions and the interpretation of non-verbal communication, very useful especially when the subjects do not appear able to formulate requests specific to their care needs.

“This role is fundamental when we (doctors) are unable to treat fundamental aspects ranging from the human / sentimental sphere to the patient who has been diagnosed with breast cancer (…) and the information to give.” Surgeon (cod. 18, 5)

“He/she [Case Manager] plays a fundamental role for another fundamental need of the patient, which is information. In the sense that you dedicate an important space to the first meeting with the new patients. Giving them a whole series of information on what the procedures are, but also clearly on which are, for example, the therapeutic strategies that he/she will have to do, the side effects that he/she can have. So we are absolutely aware of this, of the fact that it reduces psychological discomfort in an important way.” Psychologist (cod. 10, 5)

(ii) Reduction of management issues. The management of Clinical Governance is based on the formulation of clinical and care standards to be guaranteed to patients. However, they are defined with a process of strong involvement of the healthcare professionals concerned, whose purpose is the improvement of their professional performance. The Case Manager proves to be the promoter of broader, systemic approaches, capable of simultaneously affecting multiple performances and multiple dimensions such as professional, organizational and relational quality.

“I think the main role is to trace or rather to keep track of the patient’s path without obviously neglecting the relationship with the person. Relationship that we, doctors, often cannot have, due to lack of time or availability or lack of aptitude or lack of other things “ Physician (cod. 3, 2)

“He/she is committed to personalization of care as he/she enters the reality of the patient and therefore also in the different social situations of the patient. Therefore, he/she is able to help according to the difficulties that the patient presents, which can be difficulties in accessing the structure, communication difficulties, difficulties of (…) maybe social nature or in the family environment. Therefore, he/she tries to help the patient to do all the things they need, the many things often needed to reach the goal “ Oncologist (cod. 12, 2)

. This theme includes the reflections of the participants regarding the figure of the CCM. Few interviewees were aware of the new figure of the CCM. Some of them recognized that probably in their working realities the Case Manager deals not only with the logistic part, but rather is concerned above all with the emotional component of a person, bringing to light the Caring component of his role and often this happens in a little recognized way.

“In our reality, the Case Manager is also the Care Manager, in the sense that he is not a mere organizer of things, therefore. However, he is also the one who interfaces with the patient. So yes, my answer is yes. Indeed, it is desirable; in my opinion ... for me, it is a benefit, that is an added value. “ Nurse Manager (cod.17, 2)

“The Case / Care Manager as a single figure (...) as it should be, is a figure that the patient experiences as indispensable, as a reference figure throughout the diagnostic-therapeutic process” Psychologist (cod. 10,8)

The subthemes identified were: (i) being in touch with patients and their families; (ii) Case/Care Management desirable implementation in healthcare settings; (iii) integration and value of skills: the evolution of the concept of Case / Care Management; (iiii) the Lack of time: “criticality” for the role.

(i) Being in touch with patients and their families. The expressions “caring” or “to care” imply a special commitment and involvement of the healthcare professional with the person. This involvement is expressed through emotional support too. To achieve this goal, the CCM is in tune with the patient and his family with an empathic attitude and uses communicative approaches such as active listening.

“It is important not only the clinical aspect of the patient. Aspects of the care manager could be those of an educational nature, relational towards the patient or their family members ‘’ Physiotherapist (cod.3, 2)

“It is essential to listen to the patient and / or her relatives, their health needs, which can be simple or complex and of a different nature (…) I would include aspects of caring (…) in the professional practice of a case manager who wants to evolve into a Case-Care Manager ‘’ Social Worker (cod. Five, 4)

(ii) Case/Care Management desirable implementation in healthcare settings. From the interviews, it emerged that many participants expressed the desire to be able to include the figure of the CCM in all work situations, to ensure holistic care management of the assisted person.

“It is desirable that in all the other settings this fusion [between Care and Case Manager] would take place. In addition, because, we need to consider the psychological and social aspect of the person and not having only the clinical side implemented. Because theoretically it is impossible to do anything without this fusion (…) therefore there must also be the human aspect “Physiatrist (cod. 4, 1)

“Yes, absolutely. I believe that as health professionals, Case Managers are already Case / Care Managers, but the care aspect must improve over time, so it would be advisable for the different departments to have this professional figure, who can take charge of the patient already on entering the ward” Social worker (cod. 10, 8)

(iii) Integration and value of skills: the evolution of the concept of Case / Care Management. This sub-theme includes participants’ reflections regarding the process of integrating Care Management skills into Case Management. This process is described as developing the potential to increase people’s self-esteem and autonomy, to the point of positively influencing their ability to fulfill their needs, and allows to compensate for functional deficits and to develop psychophysical abilities such as to reduce the request for help and therefore becoming more independent.

“Absolutely! (…) They cannot be separated; one aspect cannot ignore the other. Therefore, while the Case component is well a case, the Care component is the care of the case (...). It is not just a data collection for a histological examination rather or like scheduling a therapy. Or, It is not a simple notebook where we put the things that concern a patient’s box, behind each of these dates, behind each of these appointments there must be a Care” Surgeon (cod. 13, 2)

“These are roles that should always be played by the same person; perhaps we cannot even separate the figure of the Case from the Care Manager in our work” Occupational Therapist (cod. 6, 2)

(iiii) the Lack of time: “criticality” for the role. Time management has the purpose of rationalizing resources, a fundamental process for the success of the care pathway. The load of responsibility that involves the CCM requires an availability in terms of time that is very often not present; this criticality creates an excessive burden and / or slowdown of processes.

“(…) it depends on the type of commitment that is required [about the CCM implementation] in my opinion because in any case I believe that the case manager already has many things to think about and with which he has to deal daily.” Physiotherapist (cod. 18, 5)

“In my opinion it’s a lot [the workload]. I mean, certainly yes, but he has to delegate some of his things to her” Neurologist (cod. 7, 6)

“It would be ideal, (…) that is, the complexity of the patient could make it difficult for a single figure to be able to manage a load of let’s say important patients” Oncologist (cod. 12, 4)

Conclusions

This research aimed to collect the perceptions of different health professionals on the relevance of the role of the case manager and of his possible evolution in the role of Case/Care Manager. The participants came from multidisciplinary care settings of varying complexity in which the figure of the case manager was present at the time of the study. In fact, these were healthcare contexts where the figure has been implemented for some time and it is present in all operating units and in care settings where it acted as an outside resource. Having said this, despite the fact that the role of the case manager has been effectively established in the last twenty years, this implementation process seemed to have occurred in a different way depending on the availability of the different healthcare setting of Italian NHS districts, and with different levels of integration and interpretation (29, 30). In the study, given the limited literature and presence of the Case/Care manager figure in the Italian NHS, we wanted to explore with the participants the possibility of implementing this role. To do this, we suggested envisioning a journey on the continuum from the concepts of cure to care (28). Although this study was initially focused on the Case Manager’ role, the analysis process results highlighted new hypotheses and further reflections (critical) concerning the explored healthcare settings. This has revealed that unfortunately, this very last figure is bound by protocols, procedures, and little freedom to explore the possible expressions of care (30, 31).

Among emerged themes, there are aspects of the care pathway management such as the need for greater continuity of care, both in hospital and in the local area. The participants defined the role of the Case Manager fundamental for the information regarding the person and his/her family entourage, thus guaranteeing an adequate clinical and therapeutic process (31). This recognition can be found in participants representations that underline how much the Case Manager is “a holder of knowledge on the possibilities of discharge that sometimes the doctors themselves do not possess” (Surgeon; cod. 13, 5).

However, the communicative aspects of this role may have limited effectiveness if adequate continuity of care is not guaranteed; this means supporting the person on the territory or in the subsequent steps of his / her care pathway (32). From this perspective, the goal of patient empowerment, as a fundamental factor for continuity of care in the area, to improve adherence to the therapeutic plan and self-care (33), may not be achieved. In our study, in line with the literature, while the Case Manager seems to have an important potential for empowerment through the use, for example, of the motivational interview (13, 33); there would seem to be no aspects (or recognized opportunities) of his/her involvement in activities “outside the protocol” (Nurse manager). Conversely, the Case/Care Manager may be in truth that professional figure who is allowed to cross the boundaries, over the procedures, so as to guarantee patient’s active involvement in his/her pathway or care plan (21).

A crucial theme of this study was health professionals’ vision of the figure of the Case/Care Manager. From the interviews carried out, it emerged that, despite the growing interest in defining such role through different empirical approaches, in Italy, this figure is still little implemented (21,29,31). In fact, the health professionals interviewed themselves were not fully aware of the meaning of its title. Therefore, the awareness of the Case/Care Manager role and its potentials emerged from the participants inductively on the stimulus offered by the interview. Deepening the discourse, it emerged that, in some of the operational realities, the case manager already possesses the characteristics of a care manager but this is not formally recognized or it is taken for granted.

In fact, according to some participants’ experiences, the logistical component of the case manager role should always acted in conjunction with an holistic management of the person and his / her family members pathway, so to guaranteeing at the same time the aforementioned “to care” and “to care” (29). In this regard, the participants were pleasantly impressed by the definition of Case/Care Management and they promised to start using it in their daily lexicon, as it fully represents a health figure with “broader perspectives”.

A critical perspective emerged from the interviews, concerned with the care component of the role which is influenced both by personal characteristics of the professional who covers it, and by the skills possessed and by the setting in which the role has been implemented. This concern found its roots within issues, already present in the literature, such as the vision of care work as a natural / personal vocation or individual attitude, the lack of time to implement soft-skills (like active listening etc.) and the misconception that the fulfillment of the role is mirrored by the success of procedures and protocols (34, 35).

A critical subtheme concerned participants’ perception of an excessive workload, which this figure should bear, in order to be able to provide for both procedural and caring aspects. These critical representations of the Case/Care Manager showed that it could be risky to concentrate different aspects of care on a single person, making it difficult to carry out a real holistic care of the assisted person. However, the participants provided some possible solutions like to delegate some functions or to envisage this role as co-shared, as already suggested by international experiences (36). On the other hand, some participants showed perplexity regarding such proposals since, for example, the Case/Care Manager delegating procedural aspects of the role to other professions, could lose that “broader point of view” needed for a holistically management process.

Lastly, the participants’ representations lead to a possible implementation and recognition of the Case/Care Manager role via the introduction of new elements and through a transformation (or expansion) of the existing Case Manager role in their related realities.

This study has some limitations. Although the convenience sampling technique allowed us to recruit a varied group of professionals from different regions and healthcare settings, it might have been more appropriate to focus, and select, the few centres where the Case/Care Management role is already in progress. However, it can be argued that, as literature highlighted, this still existing semantic confusion and interpretations of this role in Italian NHS could make difficult the search of valid centres and settings for research. Given these limitations, our findings may serve to support research questions for future studies and implementation projects of innovative health managerial roles.

The study results confirm the Case/Care Manager as the healthcare professional who deals with the management of persons’ care pathways through an individualized, integrated and interdisciplinary approach, overcoming the traditional approach centered on the single pathology or the diagnostic path, thus favoring the much-desired integration of the concepts of care and care.