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Table 3 Facilitating and impeding factors during the execution and continuation phase

From: Towards personalized integrated dementia care: a qualitative study into the implementation of different models of case management

   Intensive Linkage Nivel
Case manager characteristics    Execution Continuation Execution Continuation  
Micro level Facilitating Large case manager team made it possible to consider individual competences and a differentiated offer of tasks   +    
Increase in experience enabled case managers to discuss clients without the expert team     +  
Impeding Case manager with a dual role encounter time restraints and run a burn out risk    -   
Creating additional tasks + increase of caseloads leads to higher work pressure (especially when case managers have dual-jobs). No clear agreements about who is responsible for additional tasks     -  
Individual differences + increase in case manager team makes uniform way of practice difficult   -    
Difficulty hiring case managers with the right qualifications for the job   -    
Increase in case managers means less time per case manager to discuss clients in expert team     -  
Content of case management
Micro level Facilitating Protocols that allow case managers to indicate which clients have a priority for nursing home admission   +    
Impeding Difficulty to approach expert team when imbedded in an intramural setting and/or when crossing over to a different organization    -   
Health care agencies provide funding for a fixed number of clients but caseloads of case managers often exceed that number     -  
Indistinct quality demands on case manager tasks    - -  
No agreement on the content of the care plan and no uniform registration system     -  
Organizational structure
Meso level Facilitating Guarding and continuing the integration of case management. Preconditions are: well profiled case management, good collaboration between partners and overall satisfaction of case management by partners   +    +
A platform of directors of dementia network partners who can develop new initiatives in case management   +    
Creating a production plan for municipalities to provide insight into what type of care they purchase   +    
Impeding No clear referral procedures    -   
Not documenting what happens to responsibilities for organizational tasks on a structural basis     -  
A change in the board or employees in dementia network partners can change their motivation   -    
Collaboration with dementia care partners
Meso level Facilitating Transparency about case management practice towards dementia partners + +    
Regular meetings with social psychiatric nurses from Mental Health Care to discuss and solve collaboration issues +     
Exchanging knowledge between case managers and other disciplines increases cohesion     +  
Using existing collaboration networks to build on, e.g. networks between general practitioners and district nurses    +   
Collaboration with general practitioners, home care and day care centers can be strengthened by being each other's eyes and ears   +    
Impeding Partners have difficulty seeing case managers as equivalent to social psychiatric nurses, with whom they have experience    -   
No collaboration between the municipalities and the health care agency   -    -
Lack of transparency about division of funding from health care agencies to case management providers     -  
Quality of care
Meso level Facilitating Staying focused on individual needs of clients when discussing with care partners +     +
Commitment of the Alzheimer's Association + delegation of patients and case managers   +    +
Impeding Influence of the government who advocates primary care and care that is not disease specific     -  
As social psychiatric nurses hand over clients and tasks to case managers they lose touch with psychogeriatrics and the social chart even though clients would benefit from good collaboration between case managers and social psychiatric nurses     -  
Referral by case managers based on competing interests of providers instead on what clients need.     - -
Law & legislation/Financing
Meso level Impeding Regions made up the balance too late for an effective transfer of funds from regions with an excess of funds     -  
Financial agreement that case management can only start after diagnosis    -   
Smaller municipalities can easily drop their funding when the pressure rises, creating a gap   -    
   Without project funding administrational support for case managers was dropped     -  
Macro level Facilitating Pilot funding gave regions space to develop case management (but also caused a diversity in practice)    +   
Part of the financing from Mental Health Care could be adopted for case management +     
Introduction of the DBC: it included tasks that case managers perform   +    +
Redistributing funding across regions by health care agency based on needs of regions     +  
Impeding As project funding ended, project leaders and coordination points were omitted     -  
Lack of full insurance cover for case management led to fragmentation of financial support   -    
In some regions diagnostics and treatment are funded by the Health Insurance Act, but not in all of them   -    
   DBC does not cover all case management tasks   -    
  1. + = facilitating factor, - = impeding factor, a blank cell means a factor was not extracted from interviews in regions within this model or the Nivel study.