Is there a benefit to care management?

Care management requires nurses to engage patients with hopes of reducing costs and improving outcomes.

Care management programs often utilize direct communication between patients and nurses to encourage appropriate treatment while ultimately reducing visits to emergency rooms and hospitals. Besides working with patients, care managers also work directly with primary care physicians to help in monitoring a patient’s overall health care needs. Numerous studies have shown that these programs – when focused on patients with chronic conditions (e.g. diabetes, heart disease, heart failure, and depression) – can improve health outcomes.

A recent randomized controlled trial on telephone care management for a subset of Medicaid beneficiaries in Colorado provides new insights. The authors chose to study beneficiaries who were either blind or disabled because while this group comprises only 7% of total enrollees, their care constitutes approximately 40% of Medicaid spending. The hypothesis tested was whether or not a telephone care management approach could reduce hospital admissions and emergency room visits while also increasing preventative care services.

Using Colorado’s Medicaid claims data (2007-2011) on blind and disabled beneficiaries, the authors randomly assigned patients (ages 20-64) into a control group (n=1,524) or intervention group with care management (n=3,540). Over two years, the patients in the intervention group had contact with care managers either once every three or six months based on whether patients had moderate or high medical costs in the past. Care managers held myriad duties that included arranging transportation for physician visits and helping to find stable housing for patients.

Over two years, there appeared to be no significant difference in emergency department visits and hospital admissions between the intervention and control groups. No difference was found in visits to primary care physicians and specialists. The authors did find a statistical increase (OR 1.4; 95% CI 1.16-1.69) for the intervention group in the arena of non-physician visits (i.e. optometrists and physical therapists).

Commentary

With over twenty states having some form of care management already active in their Medicaid programs, there appears to be a great need for large, adequately powered studies that can justify the purported effects of these programs.

The authors of this study did acknowledge that the high caseloads for each case manager led to infrequent contact with patients. Optimally, contact with care managers should occur at least once per month based on successful demonstration projects. The infrequent communication between care managers and patients in this study proved to be a severe limitation.

Care management is a labor intensive intervention that requires effective communication between a nursing professional and a patient. Over-burdened care managers, as shown in this study, are ineffective at their jobs.

Changes to the care management intervention – including relieving care manager work loads and specifically targeting high-risk Medicaid beneficiaries -may prove to be more effective in achieving the goals of reducing hospitalizations, emergency visits, and improved preventive care. Should those goals be attained, many suspect the war to defray health care costs will be won.

by

Nii Darko, DO, MBA