When the Process Is the Problem: Racial/Ethnic and Language Disparities in Care Management

OBJECTIVES

Achieving health equity requires addressing disparities at every level of care delivery. Yet, little literature exists examining racial/ethnic disparities in processes of high-risk care management, a foundational tool for population health. This study sought to determine whether race, ethnicity, and language are associated with patient entry into and service intensity within a large care management program.

DESIGN

Retrospective cohort study.

METHODS

Subjects were 23,836 adult patients eligible for the program between 2015 and 2018. Adjusting for demographics, utilization, and medical risk, we analyzed the association between race/ethnicity and language and outcomes of patient selection, enrollment, care plan completion, and care management encounters.

RESULTS

Among all identified as eligible by an algorithm, Asian and Spanish-speaking patients had significantly lower odds of being selected by physicians for care management [OR 0.74 (0.58-0.93), OR 0.79 (0.64-0.97)] compared with White and English-speaking patients, respectively. Once selected, Hispanic/Latino and Asian patients had significantly lower odds compared to White counterparts of having care plans completed by care managers [OR 0.69 (0.50-0.97), 0.50 (0.32-0.79), respectively]. Patients speaking languages other than English or Spanish had a lower odds of care plan completion and had fewer staff encounters than English-speaking counterparts [OR 0.62 (0.44-0.87), RR 0.87 (0.75-1.00), respectively].

CONCLUSIONS

Race/ethnicity and language-based disparities exist at every process level within a large health system's care management program, from selection to outreach. These results underscore the importance of assessing for disparities not just in outcomes but also in program processes, to prevent population health innovations from inadvertently creating new inequities.

Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management

BACKGROUND AND OBJECTIVES

Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis.

METHODS

Mixed-methods analysis including claims using quasi-stepped-wedge design pre and postenrollment to estimate difference-in-differences, participant survey, and semistructured interviews. Participants included 1321 patients with medical, behavioral, or social needs, high utilization, in Medicaid or commercial ACOs, and enrolled in multidisciplinary, primary care-embedded care management.

RESULTS

TME significantly declined 1 to 6 months postenrollment and continued through 19 to 24 months (-$645.48 per member per month, P < .001). Emergency department and inpatient utilization significantly decreased 7 to 12 months post-enrollment and persisted through 19 to 24 months (-29% emergency department, P = .012; -82% inpatient, P < .001). Of respondents, 87.2% of survey respondents were somewhat or very satisfied with care coordination, 56.1% received education coordination when needed, and 81.5% had no unmet health needs. Emergency department or inpatient utilization decreases were consistent across payors and care manager disciplines, occurred sooner with behavioral health diagnoses, and were significant among children with above-median risk scores. Satisfaction and experience were equivalent across groups, with more unmet needs and frustration with above-median risk scores.

CONCLUSIONS

Pediatric care management in multipayor ACOs may effectively reduce TME and utilization and clinically provide high-quality care coordination, including education and family stress, with high participant satisfaction.

Reframing Value-Based Care Management: Beyond Cost Reduction and Toward Patient Centeredness

Importance

Care management programs are increasingly being utilized by health systems as a new foundational strategy to advance value-based care. These programs offer the promise of improving patient outcomes while decreasing health care utilization and costs. However, as these programs proliferate in number and specialization, the field of care management is increasingly at risk of fragmentation, inefficiency, and failure to meet the core needs of the patient.

Observations

This review of the current state of care management identifies several key challenges for the field, including an unclear value proposition, a focus on system- vs patient-centered outcomes, increased specialization by private and public entrants that produces care fragmentation, and lack of coordination among health and social service entities. A framework is proposed for reorienting care management to truly address the needs of patients through acknowledging the dynamic nature of patient care needs, providing a continuum of need-targeted programming, coordinating care among all involved entities and staff, and performing regular evaluations of outcomes that include patient-centered and health equity measures. Guidance on how this framework can be implemented within a health system and an outline of recommendations is provided for how policymakers may incentivize the development of high value and more equitable care management programs.

Conclusions and Relevance

With increased focus on care management as a cornerstone of value-based care, value-based health leaders and policymakers can improve the effectiveness and value of care management programs, reduce patient financial burden for care management services, and promote stakeholder coordination.

Impact of dementia care training on nurse care managers' interactions with family caregivers

BACKGROUND

Nurse care managers (NCM) operate through care management programs to provide care for persons living with dementia (PLWD) and interact regularly with their family caregivers; however, most do not receive formal instruction in dementia care or caregiver support. CRESCENT (CaReEcoSystem primary Care Embedded demeNtia Treatment) is a telephone-based dementia care intervention adapted from the Care EcoSystem model designed to equip NCMs with these tools. For this study, we aimed to measure intervention fidelity and understand how dementia care training impacted NCMs' provision of dementia care management services during interactions with caregivers of PLWD.

METHODS

We recruited 30 active NCMs; 15 were randomly assigned to receive training. For each nurse, we randomly selected 1-3 patients with a diagnosis of dementia in each nurse's care during January-June 2021 for a total of 54 medical charts. To assess training uptake and fidelity, we identified documentation by NCMs of CRESCENT protocol implementation in the medical records. To understand how the training impacted the amount and types of dementia care management services provided in interactions with family caregivers, we compared attention to key dementia topic areas between trained NCMs (intervention) and untrained NCMs (control).

RESULTS

Within the trained group only, community resources for PLWD, followed by safety, medication reconciliation, and advanced care planning topic areas were addressed most frequently (> 30%), while behavior management was addressed least frequently (12%). Trained NCMs were more likely to document addressing aspects of caregiver wellbeing (p = 0.03), community resources (p = 0.002), and identification of behavior (p = 0.03) and safety issues (p = 0.02) compared to those without training. There was no difference between groups in the amount of care coordination provided (p = 0.64).

CONCLUSION

Results from this study demonstrate that focused dementia care training enriches care conversations in important topic areas for PLWD and family caregivers. Future research will clarify how best to sustain and optimize high quality dementia care in care management programs with special attention to the NCM-family caregiver relationship.

TRIAL NUMBER

NCT04556097.

Intensive care management of a complex Medicaid population: a randomized evaluation

OBJECTIVES

Care management programs are employed by providers and payers to support high-risk patients and affect cost and utilization, with varied implementation. This study sought to evaluate the impact of an intensive care management program on utilization and cost among those with highest cost (top 5%) and highest utilization in a Medicaid accountable care organization (ACO) population.

STUDY DESIGN

Randomized controlled quality improvement trial of intensive care management, provided by a nonprofit care management vendor, for Medicaid ACO patients at 2 academic centers.

METHODS

Patients were identified using claims, chart review, and primary care validation, then randomly assigned 2:1 to intervention and control groups. Among 131 patients included in intent-to-treat analysis, 87 and 44 were randomly assigned to the intervention and control groups, respectively. Patients in the intervention group were eligible to receive intensive care management in the community/home setting and, in some cases, home-based primary care. Patients in the control group received standard of care, including practice-based care management. Prespecified primary outcome measures included total medical expense (TME), emergency department (ED) visits, and inpatient utilization.

RESULTS

Relative to controls, patients randomly assigned to receive intensive care management had a $1933 smaller increase per member per month in TME (P = .04) and directionally consistent but nonsignificant reductions in ED visits (17% fewer; P = .40) and inpatient admissions (34% fewer; P = .29) in the 12 months post randomization compared with the 12 months prerandomization.

CONCLUSIONS

Our study results support that targeted, intensive care management can favorably affect TME in a health system-based high-cost, high-risk Medicaid population. Further research is needed to evaluate the impact on additional clinical outcomes.

A systematic intervention to improve serious illness communication in primary care: Effect on expenses at the end of life

BACKGROUND

At a population level, conversations between clinicians and seriously ill patients exploring patients' goals and values can drive high-value healthcare, improving patient outcomes and reducing spending.

METHODS

We examined the impact of a quality improvement intervention to drive better communication on total medical expenses in a high-risk care management program. We present our analysis of secondary expense outcomes from a prospective implementation trial of the Serious Illness Care Program, which includes clinician training, coaching, tools, and system interventions. We included patients who died between January 2014 and September 2016 who were selected for serious illness conversations, using the "Surprise Question," as part of implementation of the program in fourteen primary care clinics.

RESULTS

We evaluated 124 patients and observed no differences in total medical expenses between intervention and comparison clinic patients. When comparing patients in intervention clinics who did and did not have conversations, we observed lower average monthly expenses over the last 6 ($6297 vs. $8,876, p = 0.0363) and 3 months ($7263 vs. $11,406, p = 0.0237) of life for patients who had conversations.

CONCLUSIONS

Possible savings observed in this study are similar in magnitude to previous studies in advance care planning and specialty palliative care but occur earlier in the disease course and in the context of documented conversations and a comprehensive, interprofessional case management program.

IMPLICATIONS

Programs designed to drive more, earlier, and better serious illness communication hold the potential to reduce costs.

LEVEL OF EVIDENCE

Prospectively designed trial, non-randomized sample, analysis of secondary outcomes.