Four codes emerged from the analysis: Person-centred; Acting outside the comfort zone; Successful, albeit some difficulties; Pride and satisfaction.
Person-centred
The care manager role was mainly understood as supportive and caring, although limited to a certain time period. Participants wanted to make sure that their patients were personally cared for and wanted to prevent them from feeling abandoned or left alone with unanswered questions.
The most important value for the patients, as I see it, is that; “I am not alone in this”. I say this over the phone; “we will do this together”. You shouldn’t sit at home, wondering about this (Interview (I)1).
The direct support that was given mostly concerned advice on how to maintain healthy sleeping, a healthy diet, physical activities, relaxation techniques and continuity in medication. Patients were also encouraged to engage in activities of their own liking and to find a balance in their lives. Follow-ups mainly dealt with how the patient thought about the above-mentioned areas or other personal issues that they considered important for their recovery.
The care managers described how they tried to figure out each patient’s needs, in order to provide valuable advice for how patients could enhance their self-care. Using their experience and knowledge in this consulting way was said to be appreciated by the patients.
To work as a care manager required being updated on the patient’s “personal story”, both in order to form a plan on how to proceed, but also to build a trusting relationship. Creating continuous and trusting relationships was seen as an essential condition for making the patients feel safe enough to share difficult issues about their lives.
These feelings of trust and safety are achieved after having met the patient for a while. Because they have difficult issues to share and to speak about (Focus group (FG)).
The care manager provided patients with a more accessible care, and this together with the trust and continuity that the role created was described as major advantages with the care manager function. Participants stressed that new patients could receive more rapid assistance through care managing, and that patients could keep in touch with the same care manager in case they felt worse after their eligible three months.
Participants said that on the one hand, they wanted to be emotionally engaged in their patient’s stories, but on the other hand this was considered both demanding and tiring, especially when compared to their ordinary nursing role which they felt more content with.
I think it’s a different kind of talk. It’s not a health-talk that you have with some patients, nor is it like continuously dressing a wound… I think the care-manager- talks are heavier (I 2).
All care managers stressed that the most difficult examples of this were associated with having to care for patients with too severe illnesses, whom they thought belonged to psychiatry.
Acting outside the comfort zone
Working as a care manager required the ability to understand each patient’s various needs. Participants said that the boundaries for their assignments were flexible enough, allowing them to see the broader picture, to think outside the comfort zone and to work according to their own priorities, the anchored care manager. It was clear that some patients wanted to visit the care manager more frequently or needed a great deal of emotional support, whereas others felt that a phone call every second week was enough.
In addition, participants were more comfortable with the care manager role after having adapted it in ways that better suited themselves and their patients.
I thought it was really stressful to document everything in an hour. So, I’ve changed that. Another thing is that some patients don´t want to show up in person for the last visit. If they want to take it over the phone instead, I try to make that happen (I 2).
Participants stressed that the care manager role came with additional patient-time, which gave them opportunities to develop their skills and to do more for the patients.
When you can stay with the patient for longer, this will entail something. And it will challenge your own role as well; “what can I fill this extra time with when I’m allowed to stay for a little longer?” (I 1).
An extended room for dialogue with patients was considered highly important in times when patient-time was not considered to be a priority at the primary care centres.
Although the care managers wanted to feel free when planning and executing their work, they praised the clear structure that was achieved when the model was followed. Working according to a clear model made them surer of having provided a safe and professional health care that was equal for all patients.
Participants emphasised that the self-assessment instruments MADRS-S and GAD-7 were valuable in monitoring the patients’ current situation or progress and used them as basis for discussions about what efforts to pursue next. Some participants used a template for documentation that had been provided for the care managing assignments, to get an even more structured documentation. Some participants also used the template, during the patient meeting, to clarify the patient's situation. The care managers used the templates in different ways.
The template works well to create a structure, making sure that you cover everything. Some (patients) just keep talking so that you lose track, and the talk ends up being off topic, leaving you without the right information. Then you have the template to check that you cover what you need (I 4).
Participants appreciated the regular meetings they had with other care managers. As they sometimes felt alone with difficult patient cases, it was a relief to confirm their ideas and thinking with others and to ask colleagues for advice. Additionally, sustaining the work through contact with other care managers increased their motivation and helped them keep focusing on patients with CMD on an everyday basis.
Successful, albeit some difficulties
Working in a psychosocial team was said to have several advantages. Participants believed that it made all professions more aware of patients with CMD, and through the team patients could be given the appropriate type of help at an early stage. The care manager’s work was also said to be easier to accomplish when patients could be discussed with team members.
So, we allocate the patients based on the guidelines, and as registered professionals we have the right to see patients based on what they seek care for. If the patient presents with anxiety, it’s not obvious that they should visit the GP (I 1).
An important function for the care managers in the team was to remind colleagues about how to work with patients with CMD, making sure that everyone followed the same modus operandi. Participants also tried to increase the overall knowledge about patients with CMD at the primary care centre, and they saw it as their responsibility to stand up for this patient group.
Close collaboration with other professions was said to create a more secure health care for the patients. Care managers especially wanted a successful collaboration when dealing with patients with complex needs, and several worked closely with the occupational therapists, physiotherapists, psychologists and the GP.
These patients with complex issues and a lot of various problems, they need a lot of help. It’s really good when you can sit down together and discuss these cases, and when everyone helps out (FG).
All participants felt that at times they had received patients with a mental illness that they considered too difficult for them to handle. In such cases, they kept contact with the patient until a psychologist or psychotherapist could take over.
Some care managers stressed that there had been some difficulties in convincing other professions of the value and meaning of their work, especially when the care manager function was new. A few still experienced difficulties in collaboration. As an example, one care manager was excluded from a meeting that was about planning new activities for patients with CMD. The care managers did not know how to deal with such situations, but they guessed that some colleagues did not believe in their competence or working methods.
Pride and satisfaction
Participants mostly enjoyed working as care managers and considered their job as highly meaningful. They experienced feelings of pride, happiness and relief when they saw patients’ improvements. The overall impression was that a vast majority of patients felt better after a while, both according to the patients’ spontaneous feedback and the self-assessments.
I very much enjoy working as a care manager. I believe that it’s important work, and I’ve received feedback from the patients that it plays an important role for them too (I 3).
Care managers stressed that another function they had was to support and unburden other professions, especially the GPs. Due to the many benefits that their work contributed with, participants wanted the care manager function to be strengthened and the concept to be deepened.
Care managers felt that it had been especially rewarding to receive positive feedback or gratefulness when patients explained how much their relationship had meant to them. Some participants were happily surprised that their individual conversations or phone calls seemed to have meant so much for the patient to recover.