Case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs: implementation and realist evaluations

A common reason for frequent use of health care services is the complex health care needs of individuals suffering from multiple chronic conditions, often together with mental health comorbidities and/or social vulnerability. Individuals with such complex health care needs require a variety of services from various systems and community networks. This often leads to difficulties with the integration of care. Currently, case management (CM) is the most promising intervention to improve care integration and reduce inappropriate health care use and costs for this population. Our overarching goal is to inform policy makers, clinicians, patients/families, researchers, and other primary care stakeholders about what works when using CM in primary care, for which people, under what circumstances and in what ways.