NUR 653 Module 6 Care Management Paper Example

Why Most Care Management Programs Fail and the Six Features of Those That Cut Admissions

[Student Name]

Southern New Hampshire University

NUR 653: Population Care Management

Module Six Care Management Paper

[Instructor Name]

[Date]

Why Most Care Management Programs Fail and the Six Features of Those That Cut Admissions

Care management is one of the most common strategies in population health: assign high-risk patients a nurse or other care manager who helps them manage their conditions, coordinate their care and avoid hospitalization. It is intuitive and widely adopted. It is also frequently ineffective. For two years, Mesa Valley has paid an outside vendor to provide telephone care management to about 500 high-risk patients. An internal review found no difference in hospital admissions between enrolled patients and a matched group who were eligible but not enrolled. This paper examines what the strongest evidence says about care management, identifies the features that distinguish programs that worked and compares Mesa Valley's current program with those features. It argues that care management can reduce hospital use for high-risk patients, but only when it includes specific features that most programs, including Mesa Valley's, lack.

What a Large Randomized Demonstration Found

Peikes et al. (2009) evaluated the Medicare Coordinated Care Demonstration, in which fifteen care coordination programs, run by commercial disease management companies, hospitals, academic medical centers and others, were each tested in a randomized trial with Medicare beneficiaries who had chronic conditions such as heart failure, coronary disease and diabetes. Over the first two to four years, thirteen of the fifteen programs showed no significant reduction in hospitalizations. None of the fifteen generated net savings once program fees were counted, and most had only small effects on quality of care measures. Patients generally liked the programs, which shows that satisfaction is a poor guide to effectiveness. The findings were a caution to anyone assuming that care management reduces costs.

The Six Features of Programs That Worked

Brown et al. (2012) returned to the demonstration data and examined the programs that did reduce hospital admissions among their highest-risk patients. Four programs cut admissions for these patients substantially, and they shared six features. Care managers met patients in person frequently, averaging close to one contact a month and more in person than by phone. Care managers had occasional face-to-face contact with patients' physicians. They acted as communication hubs among the physicians, hospitals and other providers caring for the patient. They delivered evidence-based patient education focused on self-management and adherence. They provided strong medication management, including reconciliation and monitoring. And they delivered timely, comprehensive transitional care after hospitalizations. The authors emphasized that effects were concentrated among high-risk patients and that programs lacking these features were unlikely to reduce admissions.

Comparing Mesa Valley's Program

Mesa Valley's vendor program lacks most of these features. Its care managers work from a call center in another state and have never met the patients or their physicians. Contact is by telephone only, averaging one call a month. Care managers have no access to Mesa Valley's electronic record, so they cannot see hospital discharges in real time, reconcile medications or communicate with the primary care team except by fax. Education follows a generic script. The vendor learns of hospitalizations from claims, typically six to eight weeks after discharge, so transitional care is impossible. The only feature partly present is education. Measured against the Brown findings, the program's lack of effect is not surprising.

Care Management Inside the Practice Team

The chronic care model offers a framework for redesign. Bodenheimer et al. (2002) argued that chronic illness goes better when patients who can manage their own care meet a practice team that has planned ahead, with support from clinical information systems, decision support, self-management support and delivery system design that assigns clear roles. Care management works best as part of that team, not as an external service. Embedded care managers can see the record, talk with physicians in the hallway, notice when a patient is admitted and arrange follow-up quickly, which is what the successful demonstration programs managed to do.

A Redesigned Model

Mesa Valley should end the vendor contract when it expires in six months and redirect the funds to embedded nurse care managers. Each of the eleven practices, or pairs of smaller practices, will have a care manager who belongs to the practice team, attends huddles and has full access to the record. Care managers will carry panels of 80 to 100 high-risk patients, selected with the stratification approach developed earlier, and will meet each patient in person at least monthly at first, at the practice or at home. They will meet with each patient's physician at least monthly to review the panel, receive real-time alerts from the regional health information exchange when patients are admitted or visit an emergency department, reconcile medications after every transition and contact patients within two days of discharge. Education will follow evidence-based self-management curricula. Every element maps to one of the six features.

Cost and Evaluation

The vendor contract costs $620,000 a year. Six embedded nurse care managers would cost about $690,000, a modest increase. Because Peikes and colleagues showed that even well-intentioned programs often fail, the redesigned program will be evaluated rigorously. Using the staggered, randomized enrollment design from the stratification paper, patients will be enrolled in waves, with those awaiting enrollment serving as a comparison group. Outcomes will include hospital admissions, emergency visits, total cost of care and patient-reported experience, and program fidelity will be measured against the six features.

The transition will be handled carefully for the 500 patients now in the vendor program. Each will receive a letter and a call explaining the change, and their records from the vendor will be transferred to the embedded care managers, who will prioritize contact with patients hospitalized in the past six months. Hiring will begin three months before the contract ends so that care managers can be trained in the six features, shadow experienced care managers at a partner organization and meet their practice teams before taking on panels.

Conclusion

The strongest evidence shows that most care management programs do not reduce hospitalizations or save money, but that programs with six specific features can reduce admissions for high-risk patients. Mesa Valley's telephone vendor program has almost none of them. Embedding nurse care managers in practice teams, with frequent in-person contact, physician connection, communication across providers, evidence-based education, medication management and timely transitional care, and evaluating the result rigorously, gives the organization a realistic chance to achieve what its current program has not.

References

Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. JAMA, 288(14), 1775-1779. https://doi.org/10.1001/jama.288.14.1775

Brown, R. S., Peikes, D., Peterson, G., Schore, J., & Razafindrakoto, C. M. (2012). Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Affairs, 31(6), 1156-1166. https://doi.org/10.1377/hlthaff.2012.0393

Peikes, D., Chen, A., Schore, J., & Brown, R. (2009). Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA, 301(6), 603-618. https://doi.org/10.1001/jama.2009.126