Case managers in France: Impact of seniority and graduation on practices and professional representations

In France, integrated care is a recent process, initially experimented during the National Alzheimer Plan 2008-2012. One of the key measures of this policy concerned the training of case managers (CMs) for elderly subjects presenting complex situations at home. All CMs received the same formation; they began exercising between 2008 and 2015. Few data are available on their opinions and professional practices. Objectives : 1/description of CMs professional practices and 2/analysis of the influence of seniority and graduation on these practices and CMs opinions on their profession. Methods : A national survey was conducted by questionnaire sent to all CMs between January and February 2016; multivariate analysis of the influence of seniority and graduation on professional practices and opinions was performed. Results : Participation rate was 78% (n = 546). Among the participants, 93% were women (median age 35 years) and 48% had a seniority of more than 2 years. At the time of the survey 52% of the CMs were graduated. On average, each CM was monitoring 23 situations. The CMs whose seniority was > 24 months had more situations in charge: 27± 8 vs 18±9 when the seniority was ≤ to 24 months (p = 0.0005). Those who were graduated also had more situations in charge: 26±8 for graduated vs 17±9 for non-graduated (p = 0.0005). CMs whose seniority was > 24 months seemed less likely to continue with case management when they met with reluctance from the patient (OR 0.4 CI 0.23-0.72 p = 0.002), and reported less often to negotiate with the person upon refusal (OR 0.44 CI 0.22-0.89 p = 0.024). When they encountered difficulties, CMs declared to be more likely to discuss situations with their colleagues rather than with their superiors (OR 1.80 CI 1.01-3.22 p = 0.046). They expressed more frequently the wish to manage fewer situations (OR 1.56 CI 1.08-2.26 p = 0.017). They considered more often that one of the specific contributions of their profession was the strengthening of the ambulatory- hospital links (OR 1.95 CI 1.07-3.57 p = 0.03). Graduated CMs reported less systematic use of the Individualized Service Plan tool than non-graduated (OR 0.43 CI 0.25- 0.75 p = 0.003). They also expressed the wish to manage fewer situations (OR 1.57 CI 1.05-2.25 p = 0.026), and to have more ethical reflection (OR 1.97 CI 1.14-3.39 p = 0.014). They considered more often that the specific contribution of their profession was an improvement in the quality of life of the accompanied persons (OR 2.81 CI 1.07-7.37 p = 0.036). Graduated CMs declared more frequently that they wanted to stop this function in the future (OR 7.78 CI 2.05-29.48 p = 0.003). Conclusion : Seniority and graduation seem to favor certain arrangements with CMs practice and modify representations. Unexpectedly, the graduation does not seem to encourage the CMs in the pursuit of their task. More studies are needed to understand why training does not strengthen CMs in their professional practice.