Studies highlight benefits of case management approaches
Different models can reduce costs
April 1, 2015
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Executive Summary
Studies found that interventions targeting high-risk patients can result in significant cost savings and reduced readmissions.
• One study found $3,700-plus in costs avoided per patient through use of care transitions intervention.
• Another study showed benefits of using evidence-based decision support tools to maximize outcomes.
• A third study highlighted the importance of targeting case management services to patients’ non-medical barriers to healthier decisions.
Case managers already know their services provide both quality and cost-saving benefits, but which models and types of services are the most beneficial? Several recent studies highlighting specific ways case management during healthcare transitions can save money and improve quality of care.
For instance, one study found that a care transitions intervention for Medicare beneficiaries resulted in about $3,700 in costs avoided per patient when compared to control groups.1
Another study found that targeting case management services using evidence-based decision support tools could maximize outcomes and minimize resource waste.2
And still other research found that people with multiple chronic conditions need consistent attention to contextual factors — the sort of non-medical factors that case managers are best equipped to address.3
“From a case management perspective, but also from the perspective of the healthcare system overall, there is increased emphasis on patient-centered care and helping patients navigate the system,” says Rosa Baier, MPH, associate director of the Center for Long-Term Care Quality and Innovation at Brown University in Providence, RI.
“This is especially important in our complex healthcare system,” Baier adds. “It’s hard for someone discharged from the hospital to figure out what to do next.”
One in five Medicare beneficiaries is admitted to the hospital within 30 days, and that number is too high, says Rebekah Gardner, MD, senior medical scientist of Healthcentric Advisors and assistant professor of medicine at Brown University.
“We need to empower patients to be better informed,” Gardner says.
One way to do this is through a coaching model that uses a case management approach that can be employed by non-RN coaching staff. Researchers found that an hour-long intervention involving care management services resulted in a prolonged positive effect.1
It reduced costs and improved patients’ understanding of how to manage their conditions, says Stefan Gravenstein, MD, a senior author of the study and interim chief of the division of geriatrics at University Hospitals Case Medical Center in Cleveland.
“The meat of the intervention is a home visit that lasts an hour on average,” Gravenstein says.
Case managers recognize that two patients of the same demographics can have very different medical circumstances, so it’s important to tailor interventions to the particular patient and the patient’s chronic health issues, notes Elizabeth Madigan, PhD, RN, FAAN, associate dean for academic affairs and professor of nursing at the Frances Payne Bolton School of Nursing, Case Western Reserve University in Cleveland.
“Most clinical practice guidelines are focused on a particular condition,” Madigan says.
Provider care is in a silo, divided by the specific disease or condition. However, patients with multiple chronic illnesses would benefit from having someone following their care in a more coordinated way, and that’s where case management can be a big benefit, she adds.
The study about community-dwelling adults focused on helping case managers and providers determine which patients need case management services and which will be fine without it, Madigan says.
“There are some predictors that say which patients need costly services, and those are the ones case managers should target,” Madigan adds.
“In the study, we took a small group of patients receiving community case management, and members of our study team provided it,” she explains. “They were given resources and time to do this case management.”
The Affordable Care Act (ACA) is moving the nation’s healthcare industry toward a more coordinated care approach, but case managers and others still are constrained, and the ability to lower costs and improve quality is hampered by the lack of coordinated care guidelines, Madigan says.
“No one puts guidelines out there that treat patients with multiple conditions,” she says. “We need to work with patients to identify what’s most important to them.”
Coordinated care also should include activities of daily living (ADLs), suggests Diane E. Holland, PhD, RN, clinical nurse researcher, division of nursing research and evidence-based practice at Mayo Clinic in Rochester, MN.
“Does a patient need help bathing or with transportation?” Holland says. “These determinants of daily life have been ignored in terms of their impact on a person’s ability to self-manage multiple conditions, and they’re ignored to both the peril of our patients and our ability to serve them.”
Holland, Madigan, and other researchers found that case management services could be made more effective with the use of evidence-based decision support tools, including prediction models based on patients’ difficulty with activities of daily living.2
“We collected data and compared costly hospital services, nursing home days, and emergency room visits,” Holland says.
Researchers found that patients with multiple chronic conditions were burdened by issues related to ADLs, including their ability to get dressed, manage their finances, and travel from one place to another, she explains.
When self-management tasks are added to the daily health burden of people with multiple chronic conditions, they can be overwhelmed. “So we have to pay attention to how well they’re managing day to day,” Holland says.
Healthcare providers will tell patients to exercise and eat more fruits and vegetables, which is good health advice. But when a patient has trouble getting dressed in the morning, the advice might not be as effective, she adds.
This suggests case managers and providers should assess the functional status of chronically ill patients. One such tool is the Live Well at Home Rapid Screen, developed by the Minnesota Department of Health. A study assessed that tool and found that patients who scored higher on the screen were more likely to use costly care.2
Tools like Live Well that measure ADLs work well as a predictor of patients’ healthcare costs for several reasons, Holland says.
“Impairments in those areas have an effect on the family’s overall ability to support an individual in the community,” she explains. “If the family can get more assistance and support, then they can continue to help that individual stay in the community for a longer period of time.”
Holland and Madigan were involved in a pilot study that addressed enhancing patient-centered care, using a community care team intervention.
The study found that patients reported more positive changes in their care when they received the intervention, versus those who were in the control group receiving usual care. The study’s community connections program was designed to be intensive and short-term, fostering active partnerships among community services and using a nurse care coordinator.4
Such partnerships have the goal of improving care collaboration and quality for chronically ill patients.
For example, a patient’s incontinence often drives families to have the person admitted to a nursing home because they don’t know how to manage it, Holland says.
Sometimes a simple solution will enable the patient to stay at home. For example, there was one woman who was incontinent and had difficulty changing her adult diapers as frequently as needed. Community service providers suggested she use a size 3 baby diaper as a pad inside the adult diaper because it was easier to change. This simple change made it possible for the woman to continue to live at home, Holland says.
Case managers can collaborate with community organizations to come up with these types of solutions.
An example of this was a diabetic patient whose health suffered from his eating out too often. The nurse care coordinator wanted him to prepare healthier meals for himself at home. It took collaboration with an elder network service provider to uncover the root cause of the man’s poor dietary habits: He was a hoarder and wanted to move to an assisted living facility so he could get more nutritious meals, but he needed help in clearing out his house, Holland says.
“We connected him with an individual to clear out his house so he could reach into his own refrigerator,” Holland says. “He’s still living independently in his home and is eating more meals at home.”
This type of community case management would be most feasible in bundled payment system where providers receive one pot of funds to provide all of their patient population’s care, Madigan notes.
Case management then would be provided to patients who were at highest risk because they were frail or had multiple conditions. “They would be people at a stage where their issues were not entirely healthcare-related, and there would be a need for conversations about the next stage of care,” Madigan says.
If the healthcare system was less siloed and smarter about prevention, then it would be more routine to target case management services toward higher risk patients, she adds.
“Case management services are expensive, but if we can target the services to the right patients then you can do a good job for patients without bankrupting the system,” Madigan says.
References
- Gardner R, Li Q, Baier RR, et al. Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge? J Gen Intern Med. 2014;29(6):878-884.
- Holland DE, Vanderboom CE, Lohse CM, et al. Exploring indicators of use of costly health services in community-dwelling adults with multiple chronic conditions. Prof Case Manag. 2015;20(1):3-11.
- Bayliss EA, Bonds DE, Boyd CM, et al. Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters. Ann Fam Med. 2014;12(3):260-269.
- Vanderboom CE, Holland DE, Lohse CM, et al. Enhancing patient-centered care: pilot study results of a community care team intervention. Western J Nurs Res. 2014;36(1):47-65.
Case managers already know their services provide both quality and cost-saving benefits, but which models and types of services are the most beneficial?
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