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Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

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• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

Published on 5 May 2022 by Shona McCombes . Revised on 30 January 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organisation, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating, and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyse the case.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

Unlike quantitative or experimental research, a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

If you find yourself aiming to simultaneously investigate and solve an issue, consider conducting action research . As its name suggests, action research conducts research and takes action at the same time, and is highly iterative and flexible. 

However, you can also choose a more common or representative case to exemplify a particular category, experience, or phenomenon.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews, observations, and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data .

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis, with separate sections or chapters for the methods , results , and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyse its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

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Definition and Philosophy of Case Management

Definition of case management.

Case Management is a dynamic process that assesses, plans, implements, coordinates, monitors, and evaluates to improve outcomes, experiences, and value.

The practice of case management is professional and collaborative, occurring in a variety of settings where medical care, mental health care, and social supports are delivered. Services are facilitated by diverse disciplines in conjunction with the care recipient and their support system.

In pursuit of health equity, priorities include identifying needs, ensuring appropriate access to resources/services, addressing social determinants of health, and facilitating safe care transitions. Professional case managers help navigate complex systems to achieve mutual goals, advocate for those they serve, and recognize personal dignity, autonomy, and the right to self-determination.

(ACMA/CCMC, September 2022)

Philosophy of Case Management

Case management is an area of specialty practice within the health and human services professions. Its underlying premise is that everyone benefits when clients(1) reach their optimum level of wellness, self-management, and functional capability. The stakeholders include the clients being served; their support systems; the health care delivery systems, including the providers of care; the employers; and the various payer sources.

Case management facilitates the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Based on the needs and values of the client, and in collaboration with all service providers, the case manager links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. This approach achieves optimum value and desirable outcomes for all stakeholders.

Case management services are optimized best if offered in a climate that allows direct communication among the case manager, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines.

Certification demonstrates that the case manager possesses the education, skills, knowledge, and experience required to render appropriate services delivered according to sound principles of practice.

(1) Client refers to the recipient of case management services. It includes, but is not limited to, consumers, clients, or patients.

Scope of practice overview 

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Case study definition

Case study, a term which some of you may know from the "Case Study of Vanitas" anime and manga, is a thorough examination of a particular subject, such as a person, group, location, occasion, establishment, phenomena, etc. They are most frequently utilized in research of business, medicine, education and social behaviour. There are a different types of case studies that researchers might use:

• Collective case studies

• Descriptive case studies

• Explanatory case studies

• Exploratory case studies

• Instrumental case studies

• Intrinsic case studies

Case studies are usually much more sophisticated and professional than regular essays and courseworks, as they require a lot of verified data, are research-oriented and not necessarily designed to be read by the general public.

How to write a case study?

It very much depends on the topic of your case study, as a medical case study and a coffee business case study have completely different sources, outlines, target demographics, etc. But just for this example, let's outline a coffee roaster case study. Firstly, it's likely going to be a problem-solving case study, like most in the business and economics field are. Here are some tips for these types of case studies:

• Your case scenario should be precisely defined in terms of your unique assessment criteria.

• Determine the primary issues by analyzing the scenario. Think about how they connect to the main ideas and theories in your piece.

• Find and investigate any theories or methods that might be relevant to your case.

• Keep your audience in mind. Exactly who are your stakeholder(s)? If writing a case study on coffee roasters, it's probably gonna be suppliers, landlords, investors, customers, etc.

• Indicate the best solution(s) and how they should be implemented. Make sure your suggestions are grounded in pertinent theories and useful resources, as well as being realistic, practical, and attainable.

• Carefully proofread your case study. Keep in mind these four principles when editing: clarity, honesty, reality and relevance.

Are there any online services that could write a case study for me?

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• v.11(2); 2022

Defining case management success: a qualitative study of case manager perspectives from a large-scale health and social needs support program

Margae knox.

1 School of Public Health, University of California, Berkeley, Berkeley, California, USA

Emily E Esteban

2 Contra Costa Health Services, Martinez, California, USA

Elizabeth A Hernandez

Mark d fleming, nadia safaeinilli, amanda l brewster, associated data.

No data are available. Data are not publicly available to protect potentially sensitive information. For data inquiries, please contact the corresponding author.

Health systems are expanding efforts to address health and social risks, although the heterogeneity of early evidence indicates need for more nuanced exploration of how such programs work and how to holistically assess program success. This qualitative study aims to identify characteristics of success in a large-scale, health and social needs case management program from the perspective of interdisciplinary case managers.

Case management program for high-risk, complex patients run by an integrated, county-based public health system.

Participants

30 out of 70 case managers, purposively sampled to represent their interdisciplinary health and social work backgrounds. Interviews took place in March–November 2019.

Primary and secondary outcome measures

The analysis intended to identify characteristics of success working with patients.

Case managers described three characteristics of success working with patients: (1) establishing trust; (2) observing change in patients’ mindset or initiative and (3) promoting stability and independence. Cross-cutting these characteristics, case managers emphasised the importance of patients defining their own success, often demonstrated through individualised, incremental progress. Thus, moments of success commonly contrasted with external perceptions and operational or productivity metrics.

Conclusions

Themes emphasise the importance of compassion for complexity in patients’ lives, and success as a step-by-step process that is built over longitudinal relationships.

What is already known on this topic?

• Case management programs to support health and social needs have demonstrated promising yet mixed results. Underlying mechanisms and shared definitions of successful case management are underdeveloped.

What this study adds?

• Case managers emphasised building trust over time and individual, patient-defined objectives as key markers of success, a contrast to commonly used quantitative evaluation metrics.

How this study might affect research, practice or policy?

• Results suggest that lighter touch case management interventions face limitations without an established patient relationship. Results also support a need for alternative definitions of case management success including patient-centered measures such as trust in one’s case manager.

Introduction

Health system efforts to address both health and social needs are expanding. In the USA, some state Medicaid programmes are testing payments for non-medical services to address transportation, housing instability and food insecurity. Medicaid provides healthcare coverage for lower income individuals and families, jointly funded by federal and state governments. Similarly, social prescribing, or the linking of patients with social needs to community resources, is supported by the UK’s National Health Service and has also been piloted by Canada’s Alliance for Healthier Communities. 1

A growing evidence base suggests promising outcomes from healthcare interventions addressing social needs. In some contexts, case managers or navigators providing social needs assistance can improve health 2 and reduce costly hospital use. 3–5 Yet systematic reviews also report mixed results for measures of health and well-being, hospitalisation and emergency department use, and overall healthcare costs. 6–9 Notably, a randomised trial of the Camden Care Coalition programme for patients with frequent hospitalisations due to medically and socially complex needs 10 found no difference in 180-day readmission between patients assigned to a care transitions programme compared with usual hospital postdischarge care. In the care transition programme, patients received follow-up from a multidisciplinary team of nurses, social workers and community health workers. The team conducted home visits, scheduled and accompanied patients to follow-up outpatient visits, helped with managing medications, coached patients on self-care and connected patients with social services and behavioural healthcare. The usual care group received usual postdischarge care with limited follow-up. 11 This heterogeneity of early evidence indicates a need for more nuanced explorations of how social needs assistance programmes work, and how to holistically assess whether programmes are successful. 12 13

Social needs case management may lead to health and well-being improvements through multiple pathways involving both material and social support. 14 15 Improvements are often a long-term, non-linear process. 16 17 At the same time, quality measures specific to social needs assistance programmes currently remain largely undefined. Studies often analyse utilisation and cost outcomes but lack granularity on interim processes and markers of success.

In order to translate a complex and context-dependent intervention like social needs case management from one setting to another, these interim processes and outcomes need greater recognition. 18–20 Early efforts to refine complex care measures are underway and call out a need for person-centred and goal-concordant measures. 21 Further research on how frontline social needs case managers themselves define successes in their work could help leaders improve programme design and management and could also inform broader quality measure development efforts.

Our in-depth, qualitative study sought to understand how case managers defined success in their work with high-risk patients. Case managers were employed by CommunityConnect, a large-scale health and social needs care management programme that serves a mixed-age adult population with varying physical health, mental health and social needs. Each case manager’s workflow includes an individualised, regularly updated dashboard of operational metrics. It is unclear, however, whether or how these operational factors relate to patient success in a complex care programme. Thus, the case managers’ perspectives on defining success are critical for capturing how programmes work and identifying essential principles.

Study design and setting

In 2017, the Contra Costa County Health Services Department in California launched CommunityConnect, a case management programme to coordinate health, behavioural health and social services for County Medicaid patients with complex health and social conditions. The County Health Services Department serves approximately 15% (180 000) of Contra Costa’s nearly 1.2 million residents. CommunityConnect enrollees were selected based on a predictive model, which leveraged data from multiple county systems to identify individuals most likely to use hospital or emergency room services for preventable reasons. Enrollees are predominantly women (59%) and under age 40 (49%). Seventy-seven per cent of enrollees have more than one chronic condition, particularly hypertension (42%), mood disorders (40%) and chronic pain (35%). 22 Programme goals include improving beneficiary health and well-being through more efficient and effective use of resources.

Each case manager interviewed in this study worked full time with approximately 90 patients at a time. Case managers met patients in-person, ideally at least once a month for 1 year, although patients sometimes continue to receive ongoing support at the case manager’s discretion in cases of continued need. Overall, up to 6000 individuals at a time receive in-person case management services through CommunityConnect, with approximately 200–300 added and 200–300 graduated per month. At the time of the study, CommunityConnect employed approximately 70 case managers trained in various public health and social work disciplines (see table 1 , Interview Sample). Case managers and patients are matched based on an algorithm that prioritises mental health history, primary language and county region.

Interview sample

Although case managers bring unique experience from their respective discipline, all are expected to conduct similar case management services. Services included discussing any unmet social needs with patients, coordinating applicable resources and partnering with the patient and patient’s care team to improve physical and emotional health. The programme tracks hospital and emergency department utilisation as well as patient benefits such as food stamps, housing or transportation vouchers and continuous Medicaid coverage on an overall basis. Each case manager has access to an individualised dashboard that includes operational metrics such as new patients to contact, and frequency of patient contacts, timeliness for calling patients recently discharged from the hospital, whether patients have continuous Medicaid coverage, and completion of social risk screenings.

Study recruitment

Semistructured interviews were conducted with 30 field-based case managers as part of the programme’s evaluation and quality improvement process. Participants included four mental health clinical specialists, five substance abuse counsellors, six social workers, nine public health nurses, four housing support specialists and two community health worker specialists. Case managers were recruited by email and selected based on purposive sampling to reflect membership across disciplines and experience working with CommunityConnect for at least 1 year. Three case managers declined to participate. Interviews ended when data saturation was achieved. 23

Interview procedures

Interviews were conducted by five CommunityConnect evaluation staff members (including EEE), who received training and supervision from the evaluation director (EH), who also conducted interviews. The evaluation staff were bachelor and masters-level trained. The evaluation director was masters-level trained and held prior experience in healthcare quality and programme planning.

The evaluation team drafted the interview guide to ask about a variety of work processes and experiences with the goal of improving programme operations including staff and patient experiences. Specific questions analysed for this study were (1) how case managers define success with a patient and (2) examples where case managers considered work with patients a success.

Interviews took place in-person in private meeting rooms at case managers’ workplace from March 2019 – November 2019. Interviews lasted 60–90 min and only the interviewer and case manager were present. All interviewers were familiar with CommunityConnect yet did not have a prior relationship with case managers. Case managers did not receive compensation beyond their regular salary for participating in the study and were allowed to opt out of recruitment or end the interview early for any reason. All interviews were audio recorded, transcribed and entered into Nvivo V.12 for analysis.

Patient and public involvement

This project focused on case manager’s perspectives and thus did not directly involve patients. Rather, patients were involved through case manager recollections of experiences working with patients.

Data analysis

We used an integrated approach to develop an initial set of qualitative codes including deductive coding of programme processes and concepts, followed by inductive coding of how case managers defined success. All interviews were coded by two researchers experienced in qualitative research (EEE and MK). Themes were determined based on recurrence across interviews and illustrative examples and being described by more than one case manager type. The two researchers identified preliminary themes independently, then consulted with one another to achieve consensus on final themes. Themes and supporting quotes were then presented to the full author team to ensure collective agreement that key perspectives had been included. Preliminary results were also shared at a staff meeting attended by case managers and other staff as an opportunity for feedback on study findings. This manuscript addresses the Standards for Reporting Qualitative Research, 24 and the Consolidated Criteria for Reporting Qualitative Research checklist is provided as an appendix. 25

All case manager participants provided informed consent. Research procedures were approved by the Contra Costa Regional Medical Center and Health Centers Institutional Review Committee (Protocol 12-17-2018).

Case managers frequently and across multiple roles mentioned three characteristics of success when working with patients: (1) establishing trust; (2) fostering change in patients’ mindset or initiative and (3) promoting stability and independence. Across these characteristics, case managers expressed that success is patient-defined, with individualised and often incremental progress—a contrast with external perceptions of success and common operational or productivity metrics (see figure 1 ).

Illustration of key themes.

Success is establishing trust

Trusting relationships were the most widely noted characteristic of success. Trust was described as both a product of case managers’ consistent follow-up and helpfulness over time and a foundational step to enable progress on patient-centred goals. To build trust, case managers explained, patients must feel seen and heard, and understand the case managers’ desire to help: ‘Success is to know that she knows me very well…I look for her on the streets, and I’m waiting for her to call me back. Hopefully she knows that when she’s ready I will be there at least to provide that resource for her and so it’s that personal relationship that you build’ (Case manager 11, social worker). Case managers also highlighted the longitudinal relationship required to establish trust, distinguishing success as more than one-time information delivery or navigating bureaucratic processes to procure services.

Case managers also identified trust as foundational to provide better support for patients: ‘So they’re as honest with me as they can be. That way I have a clear understanding about realistically what I can do to help them coordinate their care or link them to services.’ (Case manager 2, mental health clinician specialist). Establishing trust was essential to improve communication with patients and produced an amplifying effect. That is, a case manager’s initial help and follow-up builds trust so that patients can be more open, and open communication helps the case manager know what specific services can be most useful. This positive feedback loop further cements trust and builds momentum for a longitudinal relationship.

Permission to have a home visit was mentioned as a valuable indicator of early success in building trust: ‘(Your home is) your sanctuary’, expressed one case manager (Case manager 29, public health nurse), acknowledging the vulnerability of opening one’s home to an outsider. For another case manager, regular home visits in the context of a trusting relationship made the case manager aware of and able to address a difficult situation: ‘Every time I was going to her home, I was noticing more and more gnats flying around… She said it’s because of the garbage…’ After establishing trust, the patient allowed the case manager access to the bedroom where the case manager uncovered numerous soiled diapers. The case manager arranged professional cleaning and sanitation through CommunityConnect, after which, ‘there was room for a dance floor in her bedroom. There was so much room, and the look on her face, it was almost as if her chest got proud, just in that day. She didn’t seem so burdened…So that’s a success’ (Case manager 4, substance abuse counsellor). Across multiple examples, case managers expressed trust as a critical element for effective patient partnerships.

However, the pathways to building trust are less clear cut. Quick wins through tangible support such as a transportation voucher to a medical appointment could help engage a patient initially. Yet case managers more frequently emphasised strategies based on relationships over time. Strategies included expressing empathy (putting yourself in the patient’s shoes), demonstrating respect (especially when the patient has experienced disrespect in other health system encounters), keeping appointments, following through on what you say you will do, calling to check in and ‘being there’. Overall, case managers expressed that trust lets patients know they are not alone and sets the stage for future success.

Success is fostering a change in patients’ mindset or initiative

Case managers described a change in patients’ mindset or initiative as evidence of further success. One case manager explained, ‘Really (success) could be a switch in mind state… If I can get someone to consider addressing an issue. Or just acknowledging an issue. That’s progress’ (Case manager 24, substance abuse counsellor). Another case manager spoke to the importance of mindset by stating, ‘what I try to do is not just change the surface of life’. This case manager elaborated, ‘You help (a patient) get their housing and they’re gonna lose it again, unless they change; something changes in their mindset, and then they see things differently.’ (Case manager 6, mental health clinician specialist). Some case managers suggested that the supportive resources they provide are only band-aid solutions if unaccompanied by a changed mindset to address root causes.

Case managers reported that shared goals and plans are essential, in contrast to solutions identified by case managers without patient involvement. ‘I can’t do everything for them’, expressed one case manager (Case manager 21, public health nurse), while others similarly acknowledged that imposing self-improvement goals or providing resources for which a patient may not be ready may be counterproductive. Rather, one case manager emphasised, ‘I think it’s really important to celebrate people’s ideas, their beliefs, their own goals and values’. (Case manager 4, substance abuse counsellor). As an example, the case manager applauded a patient’s ideas of getting a driver’s license and completing an education certificate. In summary, case managers viewed success as a two-way street where patient’s own ideas and motivation were essential for long-term impact.

Success is promoting stability and independence

Case managers also identified patients’ stability and independence as a characteristic of success. One case manager stated, ‘I define success as having them be more independent in their just manoeuvring the system…how they problem solve’ (Case manager 30, public health nurse). Relative to the other characteristics of success, stability and independence more closely built on resources and services coordinated or procured by the case manager. For example, CommunityConnect provides cell phones free-of-charge to patients who do not currently have a phone or continuous service, which has helped patients build a network beyond the case manager: ‘Once we get them that cell phone then they’re able to make a lot of connections … linking to services on their own. They actually become a lot more confident in themselves is what I’ve seen’. (Case manager 23, substance abuse counsellor). In another example, a case manager helped a patient experiencing complex health issues to reconcile and understand various medications. For this patient stability means, ‘when he does go into the emergency room, it’s needed. … even though he’s taking his medication like he’s supposed to… it’s just his health gets bad. So, yea I would say that one (is a success)’ (Case manager 8, social worker). Thus, stability represents maintained, improved well-being, supported by care coordination and resources, even while challenges may still be present.

As a step further, ‘Absolute success’, according to one case manager, ‘(is when a patient) drops off my caseload and I don’t hear from them, not because they’re not doing well but because they are doing well, because they are independent’ (Case manager 12, social worker). Patients may still need periodic help knowing who to contact but can follow through on their own. This independence may arise because patients have found personal support networks and other resources that allow them to rely less and less on the case manager. While not all patients reach this step of sustained independence and stability, it is an accomplishment programmatically and for case managers personally.

Success is patient-defined, built on individualised and incremental progress

Case managers widely recognised that success comes in different shapes and sizes, dependent on their patient’s situation. Irrespective of the primary concern, many identified the patient’s own judgement as the benchmark for success. One case manager explained, ‘I define success with my patients by they are telling me it was a success. It’s by their expression, it’s just not a success until they say it’s a success for them’ (Case manager 7, social worker). In a more specific example, a case manager highlighted checking in with a patient instead of assuming a change is successful: ‘It’s not just getting someone housed or getting someone income. Like the male who we’re working towards reconciliation with his parents… that’s a huge step but if he doesn’t feel good about it… then that’s not a success.’ The same case manager elaborated, ‘it’s really engaging with the knowing where the patient him or herself is at mentally, for me. Yeah. That’s a success’ (Case manager 18, homeless services specialist). This comment challenges the current paradigm where, for example, if a patient has a housing need and is matched to housing, then the case is a success. Rather, case managers viewed success as more than meeting a need but also reciprocal satisfaction from the patient.

Often, case managers valued individualised, even if seemingly small, achievements as successes: ‘Every person’s different you know. A success could be just getting up and brushing their teeth. Sometimes success is actually getting them out of the house or getting the care they need’ (Case manager 28, social worker). Another case manager echoed, ‘(Success) depends on where they’re at … it runs the gamut, you know, but they’re all successes’ (Case manager 10, public health nurse). CommunityConnect’s interdisciplinary focus was identified as an important facilitator for tailoring support to individualised client needs. In contrast with condition-specific case management settings, for example, a case manager with substance abuse training noted, ‘whether someone wants to address their substance use or not, they still have these other needs, and (with CommunityConnect) I can still provide assistance’ (Case manager 24).

However, the individualised and incremental successes are not well captured by common case management metrics. One case manager highlighted a tension between operational productivity metrics and patient success, noting, ‘I get it, that there has to be accountability. We’re out in the field, I mean people could really be doing just a whole lot of nothing… (Yet), for me I don’t find the success in the numbers. I don’t think people are a number. Oh, look I got a pamphlet for you, I’m dropping it off… I don’t think that that is what’s really going to make this programme successful’ (Case manager 8, social worker). One case manager mentioned change in healthcare utilisation as a marker of success, but more often, case managers offered stories of patient success that diverge from common programme measures. For example, one case manager observed, ‘The clear (successes) are nice: when you apply for Social Security and they get it that’s like a hurrah. And then there’s other times it’s just getting them to the dentist’ (Case manager 28, social worker). Another case manager elaborated, ‘It’s not always the big number—the how many people did I house this year. It’s the little stuff like the fact that this 58-year-old woman who believes she’s pregnant and has been living outside for years and years, a victim of domestic violence, has considered going inside. Like that is gigantic’ (Case manager 18, homeless services specialist). Overwhelmingly, case managers defined success through the interpersonal relationship with their patients within patients’ complex, daily life circumstances.

Case managers’ definitions of success focused on establishing trust, fostering patients change in mindset or initiative, and, for some patients, achieving independence and stability. Examples of success were commonly incremental and specific to an individual’s circumstances, contrasting with programmatic measures such as reduction in hospital or emergency department utilisation, benefits and other resources secured, or productivity expectations. Study themes heavily emphasise the interpersonal relationship that case managers have with patients and underscore the importance of patient-centred and patient-defined definitions of success over other outcome measures.

Our results complement prior work on clinic-based programmes for complex patients. For example, interdisciplinary staff in a qualitative study of an ambulatory intensive care centre also identified warm relationships between patients and staff as a marker of success. 26 In another study interviewing clinicians and leaders across 12 intensive outpatient programmes, three key facilitators of patient engagement emerged: (1) financial assistance and other resources to help meet basic needs, (2) working as a multi-disciplinary care team and (3) adequate time and resources to develop close relationships focused on patient goals. 27 Our results concur on the importance of a multi-disciplinary approach, establishing trusting relationships, and pursuing patient-centred goals. Our results diverge on the role of resources to meet basic needs. Case managers in our study indicated that while connections to social services benefits and other resources help initiate the case manager-patient relationship, lasting success involved longer-term relationships in which they supported patients in developing patients’ own goal setting skills and motivation.

An important takeaway from case managers’ definitions of success is the ‘how’ they go about their work, in contrast to the ‘what’ of particular care coordination activities. For example, case managers emphasise interpersonal approaches such as empathy and respect over specific processes and resource availability. Primary care clinicians, too, have expressed how standard HEDIS or CAHPS quality metrics fail to capture, and in some cases disincentivise, the intuitions in their work that are important for high quality care. 28 29 Complex care management programmes must also wrestle with this challenge of identifying standards without extinguishing underlying quality constructs.

Strengths and limitations

This study brings several strengths, including bringing to light the unique, unexplored perspective of case managers working on both health and social needs with patients facing diverse circumstances that contribute to high-risk of future hospital or emergency department utilisation. The fact that our study explores perspectives across an array of case manager disciplines is also a strength, however a limitation is that we are unable to distinguish how success differed by discipline based on smaller numbers of each discipline in this study sample. Other study limitations include generalisability to other settings, given that all case managers worked for a single large-scale social needs case management programme. Comments around productivity concerns or interdisciplinary perspectives on ways to support patients may be unique to the infrastructure or management of this organisation. In addition, at the time of the study, all case managers were able to meet with patients in-person; future studies may explore whether definitions of success change when interactions become virtual or telephonic as occurred amidst COVID-19 concerns.

This study is the first to our knowledge to inquire about holistic patient success from the perspective of case managers in the context of a social needs case management programme. The findings offer important implications for researchers as well as policy makers and managers who are designing complex case management programmes.

Our results identify patient-directed goals, stability and satisfaction, as aspects of social needs case management which are difficult to measure but nonetheless critical to fostering health and well-being. Case managers indicated these aspects are most likely to emerge through a longer-term connection with their patients. Thus, while resource-referral solutions may play an important role in addressing basic needs, 30 our findings suggest that weak patient–referrer rapport may be a limitation for such lighter touch interventions. The need for sustained rapport building is also one explanation why longer time horizons may be necessary to show outcome improvements in rigorous studies. 16

Relatedly, results point to trusting relationships as an under-recognised and understudied feature of social needs case management. Existing research finds that patients’ trust in their primary care physician is associated with greater self-reported medication adherence 31 along with health behaviours such as exercise and smoking cessation. 32 Similar quantitative results have not yet been illuminated in social needs case management contexts, yet the prominence of trusting relationships in this study as well as other sources 26 27 33 34 suggests that measures of trust should be used to complement currently emphasised outcomes such as inpatient and outpatient utilisation. Future research and programme evaluation will need to develop new trust measurement or modify existing trust measures for the social needs case management context. 31 35

In summary, study themes provide waypoints of how to conceptualise programme design, new staff training and potential measurement development for complex case management programmes like CommunityConnect. Despite the broad swath of social needs addressed, case managers coalesced on establishing a trusting relationship as a necessary foundation to appropriately identify needs and facilitate connections. Second, fostering patients’ own ideas, including a change their mindset or initiative, was important to fully make use of programme resources. Third, supporting new-found independence or stability was a gratifying, but not universally achieved marker of success. Commonly, case managers highlighted moments of success with mindfulness toward small victories, illuminating that success is non-linear with no certain path nor single end point. Themes emphasise the importance of bringing compassion for the complexity in patients’ lives and developing collaborative relationships one interaction at a time.

Acknowledgments

The authors would like to thank the CommunityConnect evaluation team for their support conducting and transcribing interviews and applying preliminary coding, especially Gabriella Quintana, Alison Stribling, Julia Surges and Camella Taylor.

Contributors: MK coded and analysed qualitative data, identified key themes and related discussion areas, and drafted and critically revised the manuscript. EEE conducted interviews, coded and analysed qualitative data, and drafted and critically revised the manuscript. EH developed the study instrument, conducted interviews, supervised data collection, contributed to the data interpretation and critically revised the manuscript. MDF contributed to the interpretation and critically revised the manuscript. NS contributed to the interpretation and critically revised the manuscript. ALB contributed to the design and interpretation and critically revised the manuscript. All authors approve of the final version to be published.

Funding: MK was supported by the Agency for Healthcare Research and Quality (AHRQ) under the Ruth L. Kirschstein National Research Service Award T32 (T32HS022241). MDF was supported by the Agency for Healthcare Research and Quality, grant # K01HS027648.

Disclaimer: Its contents are solely the responsibility of the authors and do not necessarily represent the official views of AHRQ. Funding had no role in the study’s design, conduct or reporting.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by Contra Costa Regional Medical Center and Health Centers Institutional Review Committee (Protocol 12-17-2018). Participants gave informed consent to participate in the study before taking part.

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• Volume 21, Issue 1
• What is a case study?
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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Business process reengineering (BPR) is the radical redesign of core business processes to achieve dramatic improvements in performance, efficiency and effectiveness. BPR examples are not one-time projects, but rather examples of a continuous journey of innovation and change focused on optimizing end-to-end processes and eliminating redundancies. The purpose of BPR is to streamline  workflows , eliminate unnecessary steps and improve resource utilization.

BPR involves business process redesign that challenges norms and methods within an organization. It typically focuses on achieving dramatic, transformative changes to existing processes. It should not be confused with  business process management (BPM) , a more incremental approach to optimizing processes, or business process improvement (BPI), a broader term that encompasses any systematic effort to improve current processes. This blog outlines some BPR examples that benefit from a BPM methodology.

Background of business process reengineering

BPR emerged in the early 1990s as a management approach aimed at radically redesigning business operations to achieve business transformation. The methodology gained prominence with the publication of a 1990 article in the Harvard Business Review, “Reengineering Work: Don’t Automate, Obliterate,” by Michael Hammer, and the 1993 book by Hammer and James Champy, Reengineering the Corporation . An early case study of BPR was Ford Motor Company, which successfully implemented reengineering efforts in the 1990s to streamline its manufacturing processes and improve competitiveness.

Organizations of all sizes and industries implement business process reengineering. Step 1 is to define the goals of BPR, and subsequent steps include assessing the current state, identifying gaps and opportunities, and process mapping.

Successful implementation of BPR requires strong leadership, effective change management and a commitment to continuous improvement. Leaders, senior management, team members and stakeholders must champion the BPR initiative and provide the necessary resources, support and direction to enable new processes and meaningful change.

BPR examples: Use cases

Streamlining supply chain management.

Using BPR for supply chain optimization involves a meticulous reassessment and redesign of every step, including logistics, inventory management and procurement . A comprehensive supply chain overhaul might involve rethinking procurement strategies, implementing just-in-time inventory systems, optimizing production schedules or redesigning transportation and distribution networks. Technologies such as supply chain management software (SCM), enterprise resource planning (ERP) systems, and advanced analytics tools can be used to automate and optimize processes. For example, predictive analytics can be used to forecast demand and optimize inventory levels, while blockchain technology can enhance transparency and traceability in the supply chain.

• Improved efficiency
• Reduced cost
• Enhanced transparency

Customer relationship management (CRM)

BPR is a pivotal strategy for organizations that want to overhaul their customer relationship management (CRM) processes. Steps of business process reengineering for CRM include integrating customer data from disparate sources, using advanced analytics for insights, and optimizing service workflows to provide personalized experiences and shorter wait times.

BPR use cases for CRM might include:

• Implementing integrated CRM software to centralize customer data and enable real-time insights
• Adopting omnichannel communication strategies to provide seamless and consistent experiences across touchpoints
• Empowering frontline staff with training and resources to deliver exceptional service

Using BPR, companies can establish a comprehensive view of each customer, enabling anticipation of their needs, personalization of interactions and prompt issue resolution.

• 360-degree customer view
• Increased sales and retention
• Faster problem resolution

Digitizing administrative processes

Organizations are increasingly turning to BPR to digitize and automate administrative processes to reduce human errors. This transformation entails replacing manual, paper-based workflows with digital systems that use technologies like Robotic Process Automation (RPA) for routine tasks.

This might include streamlining payroll processes, digitizing HR operations or automating invoicing procedures. This can lead to can significant improvements in efficiency, accuracy and scalability and enable the organization to operate more effectively.

• Reduced processing times
• Reduced errors
• Increased adaptability

Improving product development processes

BPR plays a crucial role in optimizing product development processes, from ideation to market launch. This comprehensive overhaul involves evaluating and redesigning workflows, fostering cross-functional collaboration and innovating by using advanced technologies. This can involve implementing cross-functional teams to encourage communication and knowledge sharing, adopting agile methodologies to promote iterative development and rapid prototyping, and by using technology such as product lifecycle management (PLM) software to streamline documentation and version control.

BPR initiatives such as these enable organizations to reduce product development cycle times, respond more quickly to market demands, and deliver innovative products that meet customer needs.

• Faster time-to-market
• Enhanced innovation
• Higher product quality

Updating technology infrastructure

In an era of rapid technological advancement, BPR serves as a vital strategy for organizations that need to update and modernize their technology infrastructure. This transformation involves migrating to cloud-based solutions, adopting emerging technologies like artificial intelligence (AI) and machine learning (ML) , and integrating disparate systems for improved data management and analysis, which enables more informed decision making. Embracing new technologies helps organizations improve performance, cybersecurity and scalability and positioning themselves for long-term success.

• Enhanced performance
• Improved security
• Increased innovation

Reducing staff redundancy

In response to changing market dynamics and organizational needs, many companies turn to BPR to restructure their workforce and reduce redundancy. These strategic initiatives can involve streamlining organizational hierarchies, consolidating departments and outsourcing non-core functions. Optimizing workforce allocation and eliminating redundant roles allows organizations to reduce costs, enhance operational efficiency and focus resources on key priorities.

• Cost savings
• Increased efficiency
• Focus on core competencies

Cutting costs across operations

BPR is a powerful tool to systematically identify inefficiencies, redundancies and waste within business operations. This enables organizations to streamline processes and cut costs.

BPR focuses on redesigning processes to eliminate non-value-added activities, optimize resource allocation, and enhance operational efficiency. This might entail automating repetitive tasks, reorganizing workflows for minimizing bottlenecks, renegotiating contracts with suppliers to secure better terms, or by using technology to improve collaboration and communication. This can enable significant cost savings and improve profitability.

• Lower costs
• Enhanced competitiveness

Improving output quality

BPR can enhance the quality of output across various business processes, from manufacturing to service delivery. BPR initiatives generally boost key performance indicators (KPIs).

Steps for improving output quality involve implementing quality control measures, fostering a culture of continuous improvement, and using customer feedback and other metrics to drive innovation.

Technology can also be used to automate processes. When employees are freed from distracting processes, they can increase their focus on consistently delivering high-quality products and services. This builds customer trust and loyalty and supports the organization’s long-term success.

• Higher customer satisfaction
• Enhanced brand image

Human resource (HR) process optimization

BPR is crucial for optimizing human resources (HR) processes. Initiatives might include automating the onboarding process with easy-to-use portals, streamlining workflows, creating self-service portals and apps, using AI for talent acquisition , and implementing a data-driven approach to performance management.

Fostering employee engagement can also help attract, develop and retain top talent. Aligning HR processes with organizational goals and values can enhance workforce productivity, satisfaction and business performance.

• Faster recruitment cycles
• Improved employee engagement
• Strategic talent allocation

BPR examples: Case studies

The following case study examples demonstrate a mix of BPR methodologies and use cases working together to yield client benefits.

Bouygues becomes the AI standard bearer in French telecom

Bouygues Telecom , a leading French communications service provider, was plagued by legacy systems that struggled to keep up with an enormous volume of support calls. The result? Frustrated customers were left stranded in call lines and Bouygues at risk of being replaced by its competitors. Thankfully, Bouygues had partnered with IBM previously in one of our first pre- IBM watsonx™ AI deployments. This phase 1 engagement laid the groundwork perfectly for AI’s injection into the telecom’s call center during phase 2.

Today, Bouygues greets over 800,000 calls a month with IBM watsonx Assistant™, and IBM watsonx Orchestrate™ helps alleviate the repetitive tasks that agents previously had to handle manually, freeing them for higher-value work. In all, agents’ pre-and-post-call workloads were reduced by 30%. 1 In addition, 8 million customer-agent conversations—which were, in the past, only partially analyzed—have now been summarized with consistent accuracy for the creation of actionable insights.

Taken together, these technologies have made Bouygues a disruptor in the world of customer care, yielding a USD 5 million projected reduction in yearly operational costs and placing them at the forefront of AI technology. 1

Finance of America promotes lifetime loyalty via customer-centric transformation

By co-creating with IBM, mortgage lender Finance of America was able to recenter their operations around their customers, driving value for both them and the prospective home buyers they serve.

To accomplish this goal, FOA iterated quickly on both new strategies and features that would prioritize customer service and retention. From IBM-facilitated design thinking workshops came roadmaps for a consistent brand experience across channels, simplifying the work of their agents and streamlining the application process for their customers.

As a result of this transformation, FOA is projected to double their customer base in just three years. In the same time frame, they aim to increase revenue by over 50% and income by over 80%. Now, Finance of America is primed to deliver enhanced services—such as debt advisory—that will help promote lifetime customer loyalty. 2

BPR examples and IBM

Business process reengineering (BPR) with IBM takes a critical look at core processes to spot and redesign areas that need improvement. By stepping back, strategists can analyze areas like supply chain, customer experience and finance operations. BPR services experts can embed emerging technologies and overhaul existing processes to improve the business holistically. They can help you build new processes with intelligent workflows that drive profitability, weed out redundancies, and prioritize cost saving.

1. IBM Wow Story: Bouygues Becomes the AI Standard-Bearer in French Telecom. Last updated 10 November 2023.

2. IBM Wow Story: Finance of America Promotes Lifetime Loyalty via Customer-Centric Transformation. Last updated 23 February 2024.

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• Volume 11, Issue 2
• Defining case management success: a qualitative study of case manager perspectives from a large-scale health and social needs support program
• Article Text
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• http://orcid.org/0000-0002-5234-8610 Margae Knox 1 ,
• Emily E Esteban 2 ,
• Elizabeth A Hernandez 2 ,
• Mark D Fleming 1 ,
• Nadia Safaeinilli 1 ,
• Amanda L Brewster 1
• 1 School of Public Health , University of California, Berkeley , Berkeley , California , USA
• 2 Contra Costa Health Services , Martinez , California , USA
• Correspondence to Ms Margae Knox; margae{at}berkeley.edu

Objective Health systems are expanding efforts to address health and social risks, although the heterogeneity of early evidence indicates need for more nuanced exploration of how such programs work and how to holistically assess program success. This qualitative study aims to identify characteristics of success in a large-scale, health and social needs case management program from the perspective of interdisciplinary case managers.

Setting Case management program for high-risk, complex patients run by an integrated, county-based public health system.

Participants 30 out of 70 case managers, purposively sampled to represent their interdisciplinary health and social work backgrounds. Interviews took place in March–November 2019.

Primary and secondary outcome measures The analysis intended to identify characteristics of success working with patients.

Results Case managers described three characteristics of success working with patients: (1) establishing trust; (2) observing change in patients’ mindset or initiative and (3) promoting stability and independence. Cross-cutting these characteristics, case managers emphasised the importance of patients defining their own success, often demonstrated through individualised, incremental progress. Thus, moments of success commonly contrasted with external perceptions and operational or productivity metrics.

Conclusions Themes emphasise the importance of compassion for complexity in patients’ lives, and success as a step-by-step process that is built over longitudinal relationships.

• Health policy
• Health services research
• Patient-centred care
• Qualitative research

Data availability statement

No data are available. Data are not publicly available to protect potentially sensitive information. For data inquiries, please contact the corresponding author.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjoq-2021-001807

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What is already known on this topic?

Case management programs to support health and social needs have demonstrated promising yet mixed results. Underlying mechanisms and shared definitions of successful case management are underdeveloped.

What this study adds?

Case managers emphasised building trust over time and individual, patient-defined objectives as key markers of success, a contrast to commonly used quantitative evaluation metrics.

How this study might affect research, practice or policy?

Results suggest that lighter touch case management interventions face limitations without an established patient relationship. Results also support a need for alternative definitions of case management success including patient-centered measures such as trust in one’s case manager.

Introduction

Health system efforts to address both health and social needs are expanding. In the USA, some state Medicaid programmes are testing payments for non-medical services to address transportation, housing instability and food insecurity. Medicaid provides healthcare coverage for lower income individuals and families, jointly funded by federal and state governments. Similarly, social prescribing, or the linking of patients with social needs to community resources, is supported by the UK’s National Health Service and has also been piloted by Canada’s Alliance for Healthier Communities. 1

A growing evidence base suggests promising outcomes from healthcare interventions addressing social needs. In some contexts, case managers or navigators providing social needs assistance can improve health 2 and reduce costly hospital use. 3–5 Yet systematic reviews also report mixed results for measures of health and well-being, hospitalisation and emergency department use, and overall healthcare costs. 6–9 Notably, a randomised trial of the Camden Care Coalition programme for patients with frequent hospitalisations due to medically and socially complex needs 10 found no difference in 180-day readmission between patients assigned to a care transitions programme compared with usual hospital postdischarge care. In the care transition programme, patients received follow-up from a multidisciplinary team of nurses, social workers and community health workers. The team conducted home visits, scheduled and accompanied patients to follow-up outpatient visits, helped with managing medications, coached patients on self-care and connected patients with social services and behavioural healthcare. The usual care group received usual postdischarge care with limited follow-up. 11 This heterogeneity of early evidence indicates a need for more nuanced explorations of how social needs assistance programmes work, and how to holistically assess whether programmes are successful. 12 13

Social needs case management may lead to health and well-being improvements through multiple pathways involving both material and social support. 14 15 Improvements are often a long-term, non-linear process. 16 17 At the same time, quality measures specific to social needs assistance programmes currently remain largely undefined. Studies often analyse utilisation and cost outcomes but lack granularity on interim processes and markers of success.

In order to translate a complex and context-dependent intervention like social needs case management from one setting to another, these interim processes and outcomes need greater recognition. 18–20 Early efforts to refine complex care measures are underway and call out a need for person-centred and goal-concordant measures. 21 Further research on how frontline social needs case managers themselves define successes in their work could help leaders improve programme design and management and could also inform broader quality measure development efforts.

Our in-depth, qualitative study sought to understand how case managers defined success in their work with high-risk patients. Case managers were employed by CommunityConnect, a large-scale health and social needs care management programme that serves a mixed-age adult population with varying physical health, mental health and social needs. Each case manager’s workflow includes an individualised, regularly updated dashboard of operational metrics. It is unclear, however, whether or how these operational factors relate to patient success in a complex care programme. Thus, the case managers’ perspectives on defining success are critical for capturing how programmes work and identifying essential principles.

Study design and setting

In 2017, the Contra Costa County Health Services Department in California launched CommunityConnect, a case management programme to coordinate health, behavioural health and social services for County Medicaid patients with complex health and social conditions. The County Health Services Department serves approximately 15% (180 000) of Contra Costa’s nearly 1.2 million residents. CommunityConnect enrollees were selected based on a predictive model, which leveraged data from multiple county systems to identify individuals most likely to use hospital or emergency room services for preventable reasons. Enrollees are predominantly women (59%) and under age 40 (49%). Seventy-seven per cent of enrollees have more than one chronic condition, particularly hypertension (42%), mood disorders (40%) and chronic pain (35%). 22 Programme goals include improving beneficiary health and well-being through more efficient and effective use of resources.

Each case manager interviewed in this study worked full time with approximately 90 patients at a time. Case managers met patients in-person, ideally at least once a month for 1 year, although patients sometimes continue to receive ongoing support at the case manager’s discretion in cases of continued need. Overall, up to 6000 individuals at a time receive in-person case management services through CommunityConnect, with approximately 200–300 added and 200–300 graduated per month. At the time of the study, CommunityConnect employed approximately 70 case managers trained in various public health and social work disciplines (see table 1 , Interview Sample). Case managers and patients are matched based on an algorithm that prioritises mental health history, primary language and county region.

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Interview sample

Although case managers bring unique experience from their respective discipline, all are expected to conduct similar case management services. Services included discussing any unmet social needs with patients, coordinating applicable resources and partnering with the patient and patient’s care team to improve physical and emotional health. The programme tracks hospital and emergency department utilisation as well as patient benefits such as food stamps, housing or transportation vouchers and continuous Medicaid coverage on an overall basis. Each case manager has access to an individualised dashboard that includes operational metrics such as new patients to contact, and frequency of patient contacts, timeliness for calling patients recently discharged from the hospital, whether patients have continuous Medicaid coverage, and completion of social risk screenings.

Study recruitment

Semistructured interviews were conducted with 30 field-based case managers as part of the programme’s evaluation and quality improvement process. Participants included four mental health clinical specialists, five substance abuse counsellors, six social workers, nine public health nurses, four housing support specialists and two community health worker specialists. Case managers were recruited by email and selected based on purposive sampling to reflect membership across disciplines and experience working with CommunityConnect for at least 1 year. Three case managers declined to participate. Interviews ended when data saturation was achieved. 23

Interview procedures

Interviews were conducted by five CommunityConnect evaluation staff members (including EEE), who received training and supervision from the evaluation director (EH), who also conducted interviews. The evaluation staff were bachelor and masters-level trained. The evaluation director was masters-level trained and held prior experience in healthcare quality and programme planning.

The evaluation team drafted the interview guide to ask about a variety of work processes and experiences with the goal of improving programme operations including staff and patient experiences. Specific questions analysed for this study were (1) how case managers define success with a patient and (2) examples where case managers considered work with patients a success.

Interviews took place in-person in private meeting rooms at case managers’ workplace from March 2019 – November 2019. Interviews lasted 60–90 min and only the interviewer and case manager were present. All interviewers were familiar with CommunityConnect yet did not have a prior relationship with case managers. Case managers did not receive compensation beyond their regular salary for participating in the study and were allowed to opt out of recruitment or end the interview early for any reason. All interviews were audio recorded, transcribed and entered into Nvivo V.12 for analysis.

Patient and public involvement

This project focused on case manager’s perspectives and thus did not directly involve patients. Rather, patients were involved through case manager recollections of experiences working with patients.

Data analysis

We used an integrated approach to develop an initial set of qualitative codes including deductive coding of programme processes and concepts, followed by inductive coding of how case managers defined success. All interviews were coded by two researchers experienced in qualitative research (EEE and MK). Themes were determined based on recurrence across interviews and illustrative examples and being described by more than one case manager type. The two researchers identified preliminary themes independently, then consulted with one another to achieve consensus on final themes. Themes and supporting quotes were then presented to the full author team to ensure collective agreement that key perspectives had been included. Preliminary results were also shared at a staff meeting attended by case managers and other staff as an opportunity for feedback on study findings. This manuscript addresses the Standards for Reporting Qualitative Research, 24 and the Consolidated Criteria for Reporting Qualitative Research checklist is provided as an appendix. 25

All case manager participants provided informed consent. Research procedures were approved by the Contra Costa Regional Medical Center and Health Centers Institutional Review Committee (Protocol 12-17-2018).

Case managers frequently and across multiple roles mentioned three characteristics of success when working with patients: (1) establishing trust; (2) fostering change in patients’ mindset or initiative and (3) promoting stability and independence. Across these characteristics, case managers expressed that success is patient-defined, with individualised and often incremental progress—a contrast with external perceptions of success and common operational or productivity metrics (see figure 1 ).

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Illustration of key themes.

Success is establishing trust

Trusting relationships were the most widely noted characteristic of success. Trust was described as both a product of case managers’ consistent follow-up and helpfulness over time and a foundational step to enable progress on patient-centred goals. To build trust, case managers explained, patients must feel seen and heard, and understand the case managers’ desire to help: ‘Success is to know that she knows me very well…I look for her on the streets, and I’m waiting for her to call me back. Hopefully she knows that when she’s ready I will be there at least to provide that resource for her and so it’s that personal relationship that you build’ (Case manager 11, social worker). Case managers also highlighted the longitudinal relationship required to establish trust, distinguishing success as more than one-time information delivery or navigating bureaucratic processes to procure services.

Case managers also identified trust as foundational to provide better support for patients: ‘So they’re as honest with me as they can be. That way I have a clear understanding about realistically what I can do to help them coordinate their care or link them to services.’ (Case manager 2, mental health clinician specialist). Establishing trust was essential to improve communication with patients and produced an amplifying effect. That is, a case manager’s initial help and follow-up builds trust so that patients can be more open, and open communication helps the case manager know what specific services can be most useful. This positive feedback loop further cements trust and builds momentum for a longitudinal relationship.

Permission to have a home visit was mentioned as a valuable indicator of early success in building trust: ‘(Your home is) your sanctuary’, expressed one case manager (Case manager 29, public health nurse), acknowledging the vulnerability of opening one’s home to an outsider. For another case manager, regular home visits in the context of a trusting relationship made the case manager aware of and able to address a difficult situation: ‘Every time I was going to her home, I was noticing more and more gnats flying around… She said it’s because of the garbage…’ After establishing trust, the patient allowed the case manager access to the bedroom where the case manager uncovered numerous soiled diapers. The case manager arranged professional cleaning and sanitation through CommunityConnect, after which, ‘there was room for a dance floor in her bedroom. There was so much room, and the look on her face, it was almost as if her chest got proud, just in that day. She didn’t seem so burdened…So that’s a success’ (Case manager 4, substance abuse counsellor). Across multiple examples, case managers expressed trust as a critical element for effective patient partnerships.

However, the pathways to building trust are less clear cut. Quick wins through tangible support such as a transportation voucher to a medical appointment could help engage a patient initially. Yet case managers more frequently emphasised strategies based on relationships over time. Strategies included expressing empathy (putting yourself in the patient’s shoes), demonstrating respect (especially when the patient has experienced disrespect in other health system encounters), keeping appointments, following through on what you say you will do, calling to check in and ‘being there’. Overall, case managers expressed that trust lets patients know they are not alone and sets the stage for future success.

Success is fostering a change in patients’ mindset or initiative

Case managers described a change in patients’ mindset or initiative as evidence of further success. One case manager explained, ‘Really (success) could be a switch in mind state… If I can get someone to consider addressing an issue. Or just acknowledging an issue. That’s progress’ (Case manager 24, substance abuse counsellor). Another case manager spoke to the importance of mindset by stating, ‘what I try to do is not just change the surface of life’. This case manager elaborated, ‘You help (a patient) get their housing and they’re gonna lose it again, unless they change; something changes in their mindset, and then they see things differently.’ (Case manager 6, mental health clinician specialist). Some case managers suggested that the supportive resources they provide are only band-aid solutions if unaccompanied by a changed mindset to address root causes.

Case managers reported that shared goals and plans are essential, in contrast to solutions identified by case managers without patient involvement. ‘I can’t do everything for them’, expressed one case manager (Case manager 21, public health nurse), while others similarly acknowledged that imposing self-improvement goals or providing resources for which a patient may not be ready may be counterproductive. Rather, one case manager emphasised, ‘I think it’s really important to celebrate people’s ideas, their beliefs, their own goals and values’. (Case manager 4, substance abuse counsellor). As an example, the case manager applauded a patient’s ideas of getting a driver’s license and completing an education certificate. In summary, case managers viewed success as a two-way street where patient’s own ideas and motivation were essential for long-term impact.

Success is promoting stability and independence

Case managers also identified patients’ stability and independence as a characteristic of success. One case manager stated, ‘I define success as having them be more independent in their just manoeuvring the system…how they problem solve’ (Case manager 30, public health nurse). Relative to the other characteristics of success, stability and independence more closely built on resources and services coordinated or procured by the case manager. For example, CommunityConnect provides cell phones free-of-charge to patients who do not currently have a phone or continuous service, which has helped patients build a network beyond the case manager: ‘Once we get them that cell phone then they’re able to make a lot of connections … linking to services on their own. They actually become a lot more confident in themselves is what I’ve seen’. (Case manager 23, substance abuse counsellor). In another example, a case manager helped a patient experiencing complex health issues to reconcile and understand various medications. For this patient stability means, ‘when he does go into the emergency room, it’s needed. … even though he’s taking his medication like he’s supposed to… it’s just his health gets bad. So, yea I would say that one (is a success)’ (Case manager 8, social worker). Thus, stability represents maintained, improved well-being, supported by care coordination and resources, even while challenges may still be present.

As a step further, ‘Absolute success’, according to one case manager, ‘(is when a patient) drops off my caseload and I don’t hear from them, not because they’re not doing well but because they are doing well, because they are independent’ (Case manager 12, social worker). Patients may still need periodic help knowing who to contact but can follow through on their own. This independence may arise because patients have found personal support networks and other resources that allow them to rely less and less on the case manager. While not all patients reach this step of sustained independence and stability, it is an accomplishment programmatically and for case managers personally.

Success is patient-defined, built on individualised and incremental progress

Case managers widely recognised that success comes in different shapes and sizes, dependent on their patient’s situation. Irrespective of the primary concern, many identified the patient’s own judgement as the benchmark for success. One case manager explained, ‘I define success with my patients by they are telling me it was a success. It’s by their expression, it’s just not a success until they say it’s a success for them’ (Case manager 7, social worker). In a more specific example, a case manager highlighted checking in with a patient instead of assuming a change is successful: ‘It’s not just getting someone housed or getting someone income. Like the male who we’re working towards reconciliation with his parents… that’s a huge step but if he doesn’t feel good about it… then that’s not a success.’ The same case manager elaborated, ‘it’s really engaging with the knowing where the patient him or herself is at mentally, for me. Yeah. That’s a success’ (Case manager 18, homeless services specialist). This comment challenges the current paradigm where, for example, if a patient has a housing need and is matched to housing, then the case is a success. Rather, case managers viewed success as more than meeting a need but also reciprocal satisfaction from the patient.

Often, case managers valued individualised, even if seemingly small, achievements as successes: ‘Every person’s different you know. A success could be just getting up and brushing their teeth. Sometimes success is actually getting them out of the house or getting the care they need’ (Case manager 28, social worker). Another case manager echoed, ‘(Success) depends on where they’re at … it runs the gamut, you know, but they’re all successes’ (Case manager 10, public health nurse). CommunityConnect’s interdisciplinary focus was identified as an important facilitator for tailoring support to individualised client needs. In contrast with condition-specific case management settings, for example, a case manager with substance abuse training noted, ‘whether someone wants to address their substance use or not, they still have these other needs, and (with CommunityConnect) I can still provide assistance’ (Case manager 24).

However, the individualised and incremental successes are not well captured by common case management metrics. One case manager highlighted a tension between operational productivity metrics and patient success, noting, ‘I get it, that there has to be accountability. We’re out in the field, I mean people could really be doing just a whole lot of nothing… (Yet), for me I don’t find the success in the numbers. I don’t think people are a number. Oh, look I got a pamphlet for you, I’m dropping it off… I don’t think that that is what’s really going to make this programme successful’ (Case manager 8, social worker). One case manager mentioned change in healthcare utilisation as a marker of success, but more often, case managers offered stories of patient success that diverge from common programme measures. For example, one case manager observed, ‘The clear (successes) are nice: when you apply for Social Security and they get it that’s like a hurrah. And then there’s other times it’s just getting them to the dentist’ (Case manager 28, social worker). Another case manager elaborated, ‘It’s not always the big number—the how many people did I house this year. It’s the little stuff like the fact that this 58-year-old woman who believes she’s pregnant and has been living outside for years and years, a victim of domestic violence, has considered going inside. Like that is gigantic’ (Case manager 18, homeless services specialist). Overwhelmingly, case managers defined success through the interpersonal relationship with their patients within patients’ complex, daily life circumstances.

Case managers’ definitions of success focused on establishing trust, fostering patients change in mindset or initiative, and, for some patients, achieving independence and stability. Examples of success were commonly incremental and specific to an individual’s circumstances, contrasting with programmatic measures such as reduction in hospital or emergency department utilisation, benefits and other resources secured, or productivity expectations. Study themes heavily emphasise the interpersonal relationship that case managers have with patients and underscore the importance of patient-centred and patient-defined definitions of success over other outcome measures.

Our results complement prior work on clinic-based programmes for complex patients. For example, interdisciplinary staff in a qualitative study of an ambulatory intensive care centre also identified warm relationships between patients and staff as a marker of success. 26 In another study interviewing clinicians and leaders across 12 intensive outpatient programmes, three key facilitators of patient engagement emerged: (1) financial assistance and other resources to help meet basic needs, (2) working as a multi-disciplinary care team and (3) adequate time and resources to develop close relationships focused on patient goals. 27 Our results concur on the importance of a multi-disciplinary approach, establishing trusting relationships, and pursuing patient-centred goals. Our results diverge on the role of resources to meet basic needs. Case managers in our study indicated that while connections to social services benefits and other resources help initiate the case manager-patient relationship, lasting success involved longer-term relationships in which they supported patients in developing patients’ own goal setting skills and motivation.

An important takeaway from case managers’ definitions of success is the ‘how’ they go about their work, in contrast to the ‘what’ of particular care coordination activities. For example, case managers emphasise interpersonal approaches such as empathy and respect over specific processes and resource availability. Primary care clinicians, too, have expressed how standard HEDIS or CAHPS quality metrics fail to capture, and in some cases disincentivise, the intuitions in their work that are important for high quality care. 28 29 Complex care management programmes must also wrestle with this challenge of identifying standards without extinguishing underlying quality constructs.

Strengths and limitations

This study brings several strengths, including bringing to light the unique, unexplored perspective of case managers working on both health and social needs with patients facing diverse circumstances that contribute to high-risk of future hospital or emergency department utilisation. The fact that our study explores perspectives across an array of case manager disciplines is also a strength, however a limitation is that we are unable to distinguish how success differed by discipline based on smaller numbers of each discipline in this study sample. Other study limitations include generalisability to other settings, given that all case managers worked for a single large-scale social needs case management programme. Comments around productivity concerns or interdisciplinary perspectives on ways to support patients may be unique to the infrastructure or management of this organisation. In addition, at the time of the study, all case managers were able to meet with patients in-person; future studies may explore whether definitions of success change when interactions become virtual or telephonic as occurred amidst COVID-19 concerns.

This study is the first to our knowledge to inquire about holistic patient success from the perspective of case managers in the context of a social needs case management programme. The findings offer important implications for researchers as well as policy makers and managers who are designing complex case management programmes.

Our results identify patient-directed goals, stability and satisfaction, as aspects of social needs case management which are difficult to measure but nonetheless critical to fostering health and well-being. Case managers indicated these aspects are most likely to emerge through a longer-term connection with their patients. Thus, while resource-referral solutions may play an important role in addressing basic needs, 30 our findings suggest that weak patient–referrer rapport may be a limitation for such lighter touch interventions. The need for sustained rapport building is also one explanation why longer time horizons may be necessary to show outcome improvements in rigorous studies. 16

Relatedly, results point to trusting relationships as an under-recognised and understudied feature of social needs case management. Existing research finds that patients’ trust in their primary care physician is associated with greater self-reported medication adherence 31 along with health behaviours such as exercise and smoking cessation. 32 Similar quantitative results have not yet been illuminated in social needs case management contexts, yet the prominence of trusting relationships in this study as well as other sources 26 27 33 34 suggests that measures of trust should be used to complement currently emphasised outcomes such as inpatient and outpatient utilisation. Future research and programme evaluation will need to develop new trust measurement or modify existing trust measures for the social needs case management context. 31 35

In summary, study themes provide waypoints of how to conceptualise programme design, new staff training and potential measurement development for complex case management programmes like CommunityConnect. Despite the broad swath of social needs addressed, case managers coalesced on establishing a trusting relationship as a necessary foundation to appropriately identify needs and facilitate connections. Second, fostering patients’ own ideas, including a change their mindset or initiative, was important to fully make use of programme resources. Third, supporting new-found independence or stability was a gratifying, but not universally achieved marker of success. Commonly, case managers highlighted moments of success with mindfulness toward small victories, illuminating that success is non-linear with no certain path nor single end point. Themes emphasise the importance of bringing compassion for the complexity in patients’ lives and developing collaborative relationships one interaction at a time.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by Contra Costa Regional Medical Center and Health Centers Institutional Review Committee (Protocol 12-17-2018). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors would like to thank the CommunityConnect evaluation team for their support conducting and transcribing interviews and applying preliminary coding, especially Gabriella Quintana, Alison Stribling, Julia Surges and Camella Taylor.

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Contributors MK coded and analysed qualitative data, identified key themes and related discussion areas, and drafted and critically revised the manuscript. EEE conducted interviews, coded and analysed qualitative data, and drafted and critically revised the manuscript. EH developed the study instrument, conducted interviews, supervised data collection, contributed to the data interpretation and critically revised the manuscript. MDF contributed to the interpretation and critically revised the manuscript. NS contributed to the interpretation and critically revised the manuscript. ALB contributed to the design and interpretation and critically revised the manuscript. All authors approve of the final version to be published.

Funding MK was supported by the Agency for Healthcare Research and Quality (AHRQ) under the Ruth L. Kirschstein National Research Service Award T32 (T32HS022241). MDF was supported by the Agency for Healthcare Research and Quality, grant # K01HS027648.

Disclaimer Its contents are solely the responsibility of the authors and do not necessarily represent the official views of AHRQ. Funding had no role in the study’s design, conduct or reporting.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Read the full text or download the PDF:

• Study guide
• 1.1. Definition and classification of waste
• 1.2. Global generation of waste
• 1.3. Problems caused by mismanagement of waste
• 2.1. Main principles of waste management
• 2.2. Economics of waste management
• 3.1. Waste management actors and governance problems
• 3.2. Sustainable development goals and international agreements
• 3.3. National laws
• 3.4. Economic tools
• 4.1. Waste audit strategy
• 4.2. Audit design matrix
• 4.3. Audit methods
• 4.4. Cooperative audits
• Useful links
• Course team

MOOC: Auditing waste management

Waste is a product or substance which is no longer suited for its intended use. Whereas in natural ecosystems waste (i.e. oxygen, carbon dioxide and dead organic matter) is used as food or a reactant, waste materials resulting from human activities are often highly resilient and take a long time to decompose.

For legislators and governments, defining and classifying waste based on risks related to the environment and human health are therefore important in order to provide appropriate and effective waste management. For the producer or holder, assessing whether a material is waste or not is important in identifying whether waste rules should be followed. Definitions are also relevant in the collection and analysis of waste data as well as in domestic and international reporting obligations.

Waste has been defined in most countries and is generally tied to the concept of disposal.

On the more detailed level, a notable variety of definitions and classification approaches are used globally. Materials and substances that are directed for recycling or re-use are often (but not always) regarded as waste since the producer or holder discards them and they will only cease to be waste if certain procedures are completed and documented. Defining waste can at times also be a case-by-case decision. For example, industrial by-products can on certain conditions be regarded as non-waste. The national waste regulation is the main reference point in this regard.

Waste can be classified based on source (who/what generated the waste? See Figure 1 ), substance (what is it made of?), hazard properties (how dangerous is it?), management (who handles it?) or a mix of these concepts.

Figure 1. Waste classification by origin. Different activities generate different types of waste.

Source: National Audit Office of Estonia

Two main waste categories can be established based on the distinct legislation and policy instruments usually in place: non-hazardous or solid waste; and hazardous waste. Such a classification is also used in the Basel Convention. Hazardous waste is usually regulated at the national level, while non-hazardous is regulated at the regional or local (municipal) level. ( See Figure 2. )

Figure 2. Classification of waste

Non-hazardous/solid waste is all waste which has not been classified as hazardous: paper, plastics, glass, metal and beverage cans, organic waste etc. While not hazardous, solid waste can have serious environmental and health impact if left uncollected and untreated (explained further in chapter  1.3. ). While a significant proportion of solid waste could theoretically be reused or recycled, collection by type of waste (selective waste collection) – a prerequisite for reuse and recycling – is one of the biggest waste management challenges.

Hazardous waste is waste that has been identified as potentially causing harm to the environment and human health and therefore needs special, separate treatment and handling (refer also to   chapter 1.3. ). Chemical and physical characteristics determine the exact collection and recycling process. Flammability, corrosiveness, toxicity, ecotoxicity and explosiveness are the main characteristics of hazardous waste. Liquid, gaseous and powder waste need special treatment by default to avoid the dispersal of the waste. Generally, separate collection and handling are established to avoid contact with non-hazardous waste. Chemical treatment, incineration or high-temperature treatment, safe storage, recovery and recycling are possible modes of treatment for hazardous waste. Most hazardous waste originates from industrial production. Special kinds of hazardous waste include:

• E-waste is waste from electric and electronic equipment such as end-of-life computers, phones and home appliances. E-waste is generally classified as hazardous because it contains toxic components (e.g. PCB and various metals).
• Medical waste originates from the human and animal healthcare systems and usually consists of medicines, chemicals, pharmaceuticals, bandages, used medical equipment, bodily fluids and body parts. Medical waste can be infectious, toxic or radioactive or contain bacteria and harmful microorganisms (including those that are drug-resistant).
• Radioactive waste contains radioactive materials. The management of radioactive waste differs significantly from that of other waste. Auditing the management of radioactive waste is not the subject of this MOOC.

AUDIT CASE: MEDICAL WASTE MANAGEMENT

Thinking exercise.

• How are waste issues regulated in your country? Is there special waste act? Was it easy it to find the waste act or other relevant materials?