Case Management Program Highlights Challenges of Working with High-Need Populations
By Melinda Young
Care coordinators and case managers know their work makes a positive difference in patients’ lives, but proving this is challenging.
For example, the Camden Coalition Care Management Program demonstrated some positive outcomes related to high-cost, high-need patients, including increasing patients’ visits with providers within two weeks after their hospitalizations. However, it did not change their rate of readmissions. The targeted population included people with the highest rates of hospital readmissions. The patients had complex conditions, often were homeless, and experienced issues with substance use, mental illness, and other social determinants of health. Their hospitalization rates were similar to comparable patient populations.1,2
Care Coordination Model
In studying why the results did not show a decrease in the rehospitalization rate, investigators concluded that it might have been because care coordination and case management were helpful but not enough to effect that level of change with such a complex, high-need population.1
“Care coordination is insufficient to address their needs,” says Jesse Gubb, PhD, study co-author and senior research manager at J-PAL (Abdul Latif Jameel Poverty Action Lab) North America at the Massachusetts Institute of Technology.
The program is a model of care coordination. It enrolls patients to work with a multidisciplinary care team, including a nurse, community health worker, and social worker. The team conducts home visits and schedules patients to meet with primary care and specialty care providers. They visit homes over several months and coordinate follow-up care and medication management, Gubb says.
“If there’s a particular routine a person is supposed to do at home, [the team] makes sure [patients] understand discharge instructions,” he explains. “They set goals with patients and help them apply for other social service programs they may need and be eligible for, like housing support.”
The care coordination team provides intensive support on both clinical and social components of their care. All this was positive, but it was not enough to keep patients out of the hospital.
“For our main outcome, there was no difference between hospital readmissions. It was a disappointing result. It launched debate on what to do next,” Gubb says. “As researchers, we were not able to say much. We knew the program had null results, but we didn’t know why.”
There were theories about why increased care coordination and case management did not dent the overall readmission rates, Gubb says. The first theory was that this type of care coordination program was insufficient, and an expansion of services was necessary. The second theory was that care coordination could not help people who had suffered a lifetime of trauma and health problems. Another was that care coordination could work but should be done differently.
Imperfect Implementation
Gubb and colleagues found that the implementation of care coordination was imperfect. The care coordination team succeeded in increasing patients’ ambulatory office visits within 14 days of discharge from the hospital. Among the care coordination group, 42.35% visited a provider in that period. By comparison, 27.14% of the control group saw a provider within two weeks. However, 42% is considerably less than the ideal of every patient seeing a physician soon after discharge.
“We had ambitious goals,” Gubb notes. “We had important intermediate successes.”
The successes improved patient care quality but did not affect hospitalizations, which is one of the biggest factors contributing to healthcare costs. “We found that the program had a significant effect in interim outcomes, including increases in access to primary and secondary care and to medical equipment,” Gubb explains. “This suggests that care coordination alone is insufficient to reduce hospitalizations for this population.”
For instance, intensive care management could break down barriers that prevented more than half of complex care patients from meeting with their physicians soon after discharge. These barriers included a lack of available appointments, lack of transportation, difficulty connecting with clients without a stable phone number, and social determinants of health (e.g., homelessness and mental health challenges).
When someone is experiencing homelessness, it is difficult to help them improve their care management until they achieve stable housing. “Getting them into a home is a first step,” Gubb says.
Also, it might not be worthwhile to put even more resources into getting patients to their providers within two weeks of discharge. Other actions might have a bigger effect on rehospitalizations.
“We could be focusing on housing, legal issues, and all these issues of complexity,” Gubb says. “The idea that we connect people to existing services is insufficient. I don’t know what those solutions are. It cries out for more evaluation into the nonclinical aspects of housing, cash, food as medicine, and a variety of things that fit into the broader social determinants of health bucket.”
Researchers and healthcare organizations need to test more interventions. For example, the Camden Coalition Care Management Program is continually tweaking its program based on the research. “They added additional elements to their program, like housing and legal services, that they’re focusing on. There’s a greater focus on mental health,” Gubb says. “We’d be excited to evaluate things like that with them or with other partners. They’re an important thought leader in complex care.”
REFERENCES
- Finkelstein A, Cantor JC, Gubb J, et al. The Camden Coalition Care Management Program improved intermediate care coordination: A randomized controlled trial. Health Aff (Millwood) 2024;43:131-139.
- Finkelstein A, Zhou A, Taubman S, Doyle J. Health care hotspotting — A randomized, controlled trial. N Engl J Med 2020;382:152-162.
Care coordinators and case managers know their work makes a positive difference in patients’ lives, but proving this is challenging. For example, the Camden Coalition Care Management Program demonstrated some positive outcomes related to high-cost, high-need patients, including increasing patients’ visits with providers within two weeks after their hospitalizations. However, it did not change their rate of readmissions.
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