title: Effect of care management program structure on implementation: a normalization process theory analysis.
abstract: Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice.
  
  
  
  Data collection involved semi-structured interviews and observations conducted at 25 practices in five physician organizations in Michigan, USA. Practices were selected to reflect variation in physician organizations, type of care management program, and degree of normalization. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with NPT as a guiding framework.
  
  
  
  Seventy interviews and 25 observations were completed. Two key structures for care management organization emerged: practice-based care management where the care managers were embedded in the practice as part of the practice team; and centralized care management where the care managers worked independently of the practice work flow and was located outside the practice. There were differences in normalization of care management across practices. Practice-based care management was generally better normalized as compared to centralized care management. Differences in normalization were well explained by the NPT, and in particular the collective action construct. When care managers had multiple and flexible opportunities for communication (interactional workability), had the requisite knowledge, skills, and personal characteristics (skill set workability), and the organizational support and resources (contextual integration), a trusting professional relationship (relational integration) developed between practice providers and staff and the care manager. When any of these elements were missing, care management implementation appeared to be affected negatively.
  
  
  
  Although care management can introduce many new changes into delivery of clinical practice, implementing it successfully as a new complex intervention is possible. NPT can be helpful in explaining differences in implementing a new care management program with a view to addressing them during implementation planning.
authors.affiliation: Department of Family Medicine, University of Colorado Denver School of Medicine, 12631 E. 17th Avenue, Mail stop F-496, Aurora, CO, 80045, USA. jodi.holtrop@ucdenver.edu.
authors.forename: Jodi Summers
authors.initials: JS
authors.lastname: Holtrop
authors.affiliation: Department of Health Policy, Management, and Behavior, School of Public Health, University at Albany, State University of New York, Albany, NY, USA.
authors.forename: Georges
authors.initials: G
authors.lastname: Potworowski
authors.affiliation: Department of Family Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
authors.forename: Laurie
authors.initials: L
authors.lastname: Fitzpatrick
authors.affiliation: Priority Health, Grand Rapids, MI, USA.
authors.forename: Amy
authors.initials: A
authors.lastname: Kowalk
authors.affiliation: Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.|Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
authors.forename: Lee A
authors.initials: LA
authors.lastname: Green
mesh_terms: D000066491:Clinical Decision-Making; D003625:Data Collection; D006801:Humans; D007407:Interviews as Topic; D008329:Managed Care Programs / Q000458:organization & administration*; D008824:Michigan / Q000453:epidemiology; D011320:Primary Health Care / Q000458:organization & administration*; D016730:Program Development
keywords: Care management; Chronic disease; Normalization Process Theory; Primary care