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

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