A Comparison of Health Plan- and Provider-Delivered Chronic Care Management Models on Patient Clinical Outcomes

Organisational models in primary health care to manage chronic conditions: A scoping review

Chronic diseases are increasing incessantly, and more efforts are needed in order to develop effective organisational models in primary health care, which may address the challenges posed by the consequent multimorbidity. The aim of this study was to assess and map methods, interventions and outcomes investigated over the last decade regarding the effectiveness of chronic care organisational models in primary care settings. We conducted a scoping review including systematic reviews, clinical trials, and observational studies, published from 2010 to 2020, that evaluated the effectiveness of organisational models for chronic conditions in primary care settings, including home care, community, and general practice. We included 67 international studies out of the 6,540 retrieved studies. The prevalent study design was the observational design (25 studies, 37.3%), and 62 studies (92.5%) were conducted on the adult population. Four main models emerged, called complex integrated care models. These included models grounded on the Chronic Care Model framework and similar, case or care management, and models centred on involvement of pharmacists or community health workers. Across the organisational models, self-management support and multidisciplinary teams were the most common components. Clinical outcomes have been investigated the most, while caregiver outcomes have been detected in the minority of cases. Almost one-third of the included studies reported only significant effects in the outcomes. No sufficient data were available to determine the most effective models of care. However, more complex models seem to lead to better outcomes. In conclusion, in the development of more comprehensive organisational models to manage chronic conditions in primary health care, more efforts are needed on the paediatric population, on the inclusion of caregiver outcomes in the effectiveness evaluation of organisational models and on the involvement of social community resources. As regarding the studies investigating organisational models, more detailed descriptions should be provided with regard to interventions, and the training, roles and responsibilities of health and lay figures in delivering care.

Transitional Care Models for High-Need, High-Cost Adults in the United States: A Scoping Review and Gap Analysis

Purpose of Study:

This scoping review explored research literature on the integration and coordination of services for high-need, high-cost (HNHC) patients in an attempt to answer the following questions: What models of transitional care are utilized to manage HNHC patients in the United States ? and How effective are they in reducing low-value utilization and in improving continuity ?

Primary Practice Settings:

U.S. urban, suburban, and rural health care sites within primary care, veterans’ services, behavioral health, and palliative care.

Methodology and Sample:

Utilizing the Joanna Briggs Institute and PRISMA guidelines for scoping reviews, a stepwise method was applied to search multiple databases for peer-reviewed published research on transitional care models serving HNHC adult patients in the United States from 2008 to 2018. All eligible studies were included regardless of quality rating. Exclusions were foreign models, studies published prior to 2008, review articles, care reports, and studies with participants younger than 18 years. The search returned 1,088 studies, of which 19 were included.

Results:

Four studies were randomized controlled trials and other designs included case reports and observational, quasi-experimental, cohort, and descriptive studies. Studies focused on Medicaid, Medicare, dual-eligible patients, veterans, and the uninsured or underinsured. High-need, high-cost patients were identified on the basis of prior utilization patterns of inpatient and emergency department visits, high cost, multiple chronic medical diagnoses, or a combination of these factors. Tools used to identify these patients included the hierarchical condition category predictive model, the Elder Risk Assessment, and the 4-year prognostic index score. The majority of studies combined characteristics of multiple case management models with varying levels of impact.

Implications for Case Management Practice:

Stakeholder impact on the implementation of integrated care: Opportunities to consider for patient-centered outcomes research

Nearly half of Americans live with chronic disease. Many have multiple chronic conditions that often present as a combination of physical and mental health conditions. Aligning stakeholder-driven, patient-centered outcomes research with population health strategies such as innovative ways to deliver care management can reduce the burden of multiple chronic conditions. In addition, successfully creating meaningful, inclusive research requires actively engaging stakeholders throughout the lifecycle of a study. This study integrates stakeholder engagement, using a large health plan in western Pennsylvania, to conduct a randomized controlled trial. Three care management strategies, High-Touch, High-Tech, and Usual Care, are compared for effectiveness among members with multiple chronic conditions. Care strategies are delivered via the Community Team, a multidisciplinary community-based team, offering in-person (High-Touch) and digital (High-Tech) care management in 14 counties across Pennsylvania. Participants are followed for 12months, with repeated measurements of self-reported health status and activation in care, while tracking administrative measurements of primary and specialty health service utilization. Quality of life, care satisfaction, engagement in care, and service utilization will be compared using generalized mixed models. Additionally, semi-structured interviews are conducted for both participants and care managers over the course of the study to evaluate feasibility. This manuscript presents implementation strategies, while noting that the implementation of patient-centered outcomes research in a real-world setting requires rapid evaluation, redesign of workflow, and tailored approaches for success.

"It's Tricky": Care Managers' Perspectives on Interacting with Primary Care Clinicians

Care management programs that facilitate collaboration between care managers and primary care clinicians are more likely to be successful in improving chronic disease metrics than programs that do not facilitate such collaboration. The authors sought to understand care managers' perspectives on interacting with primary care clinicians. Semi-structured qualitative interviews were conducted with care managers (n = 29) from 3 health systems in and around a large, urban academic center. Interviews were audio recorded, transcribed verbatim, and iteratively analyzed using a grounded theory approach. Care managers worked for health plans (14%), outpatient specialty clinics (31%), hospitals and emergency departments (24%), and primary care offices (14%). Care managers identified the primary care clinician as leading patients' care and as essential to avoiding unnecessary utilization. Care managers described variability in and barriers to interacting with primary care clinicians. When possible, care managers use the electronic medical record to facilitate interaction rather than communicating directly (eg, phone call) with primary care clinicians. The role of the care manager varied across programs, contributing to primary care clinicians' poor understanding of what the care manager could provide. Consequently, primary care clinicians asked the care manager for help with tasks beyond his/her role. Care managers felt inferior to primary care clinicians, a potential result of the traditional medical hierarchy, which also hindered interactions. Although care managers view interactions with the primary care clinician as essential to the health of the patient, communication challenges, variability of the care manager's role, and medical hierarchy limit collaboration.

Patient perception matters in weight management

In a survey of 471 patients, we collected self-reported weight and height data and asked about self-perceptions of provider support toward weight loss and other weight management concerns. Multivariable analysis found that respondents with higher body mass index (BMI) were more likely to report that a physician had told them that they were overweight (OR=3.49, 95% CI 2.06-5.89, P<0.001). However, this conversation was less likely to change their personal view of their weight (OR=0.62 per 5 kg/m2, 95% CI 0.45-0.86, P=0.004), or motivate them to lose weight (OR=0.67 per 5 kg/m2, 95% CI 0.50-0.91, P=0.009). Higher BMI was associated with higher weight-loss goals (P<0.001), while anticipated time to achieve those goals was increased (P<0.001). Physician involvement in weight management was important, but the patients' needs and experiences differed by BMI. Approaches to addressing barriers and identifying resources for weight management should be tailored to individuals by considering BMI.

Effect of care management program structure on implementation: a normalization process theory analysis

Background

Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice.

Methods

Data collection involved semi-structured interviews and observations conducted at 25 practices in five physician organizations in Michigan, USA. Practices were selected to reflect variation in physician organizations, type of care management program, and degree of normalization. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with NPT as a guiding framework.

Results

Seventy interviews and 25 observations were completed. Two key structures for care management organization emerged: practice-based care management where the care managers were embedded in the practice as part of the practice team; and centralized care management where the care managers worked independently of the practice work flow and was located outside the practice. There were differences in normalization of care management across practices. Practice-based care management was generally better normalized as compared to centralized care management. Differences in normalization were well explained by the NPT, and in particular the collective action construct. When care managers had multiple and flexible opportunities for communication (interactional workability), had the requisite knowledge, skills, and personal characteristics (skill set workability), and the organizational support and resources (contextual integration), a trusting professional relationship (relational integration) developed between practice providers and staff and the care manager. When any of these elements were missing, care management implementation appeared to be affected negatively.

Conclusions

Although care management can introduce many new changes into delivery of clinical practice, implementing it successfully as a new complex intervention is possible. NPT can be helpful in explaining differences in implementing a new care management program with a view to addressing them during implementation planning.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1613-1) contains supplementary material, which is available to authorized users.