Physicians' view of primary care-based case management for patients with heart failure: a qualitative study

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Abstract
As part of a trial aiming to improve care for patients with chronic (systolic) heart failure, a standardized, multifaceted case management approach was evaluated in German general practices. It consisted of regular telephone monitoring, home visits, health counselling, diagnostic screening and booklets for patients. Practice-based doctors' assistants (equivalent to a nursing role) adopted these new tasks and reported regularly to the employing general practitioner (GP). To explore GPs' perceptions of case management, subsequent changes in relationships within the practice team and the potential future role. Twenty-four GPs participated in five moderated, semi-structured, audio-taped focus groups. Full transcription and thematic content analysis was undertaken. GPs rated all elements and instruments of case management conducted by doctors' assistants feasible, except for the geriatric assessment as patients had not been at risk. GPs perceived difficulties in their own role in delivering health behaviour counselling. Relationships between doctors' assistants and patients and between GPs and patients or doctors' assistants remained stable or improved. All GPs perceived a variety of role changes in doctors' assistants including more in-depth medical knowledge and higher responsibilities yielding more recognition by patients and GPs. Some GPs suggested transferring the case management programme to other chronic conditions and that it should form part of a further education curriculum for doctors' assistants. This primary care-based case management model characterized by the orchestrated delegation of tasks to doctors' assistants offers a promising strategy of enhanced chronic illness care, but it needs further adaptation and evaluation.