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THE SYNTHESIS PROJECT

NEW INSIGHTS FROM RESEARCH RESULTS

RESEARCH SYNTHESIS REPORT NO. 19 DECEMBER 2009 Thomas Bodenheimer, MD, MPH Rachel Berry-Millett, BA Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California, San Francisco

Care management of patients with complex health care needs

See companion Policy Brief available at

TABLE OF CONTENTS

1 Introduction 3 Methodological overview 4 Findings 17 Implications for policy-makers 19 The need for additional information

APPENDICES 20 Appendix I: References 25 Appendix II: Methodological discussion 26 Appendix III: Descriptions of care management programs 32 Appendix IV: Summaries of selected controlled studies 34 Appendix V: Summary of Medicare care

management demonstrations

THE SYNTHESIS PROJECT (Synthesis) is an initiative of the Robert Wood Johnson Foundation to produce relevant, concise, and thought-provoking briefs and reports on today's important health policy issues. By synthesizing what is known, while weighing the strength of findings and exposing gaps in knowledge, Synthesis products give decision-makers reliable information and new insights to inform complex policy decisions. For more information about the Synthesis Project, visit the Synthesis Project's Web site at . For additional copies of Synthesis products, please go to the Project's Web site or send an e-mail request to pubsrequest@.

SYNTHESIS DEVELOPMENT PROCESS

1 Audience Suggests Topic

2 Scan Findings

3 Weigh Evidence

4

Synthesize Results

POLICY IMPLICATIONS

5

Distill for Policy-Makers

6

Expert Review by Project Advisors

Introduction

A high percentage of health care expenditures are associated with a small proportion of the population -- people with complex health care needs. Most patients in this high-cost group are Medicare beneficiaries with multiple chronic conditions, frequent hospitalizations, and limitations on their ability to perform basic daily functions due to physical, mental and psychosocial challenges.

The growth in Medicare expenditures for beneficiaries with five or more chronic conditions is striking, jumping from 52 percent of total Medicare spending in 1987 to 76 percent in 2002 (Figure 1). Health care spending for people with five or more chronic conditions is 17 times higher than for people with no chronic conditions (Figure 2). Given the 73 percent projected growth in the next 10 years of the over-65 population and the far higher prevalence of complex health care needs among this group, the costs of providing care for this population sector threatens Medicare's future viability.

Figure 1. Medicare spending for beneficiaries with 5 or more conditions

1987

52%

1997

65%

2002

0

20

40

Source: Thorpe and Howard (111)

76%

60

80

100%

Figure 2: Average per capita spending by number of chronic conditions

Average per capita spending $20,000

$16,819

15,000

10,000

5,000 $994

$2,753

$5,062

$7,381

$10,091

0 0

1

2

3

4

5+

Number of chronic conditions

Source: Anderson (2)

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Introduction

For patients with complex health care needs, the issues of cost and quality are intertwined. For example, patients experiencing quality of care problems are likely to have more hospitalizations due to complications associated with poor quality of care. Therefore, days spent in the hospital per year is both a cost measure and a quality measure. High-cost measures such as hospitalizations, emergency department care and nursing home stays also may indicate poorer quality of life. For example, elderly patients generally report a better quality of life if they can avoid hospitalization, remain in their homes, and visit their own physician's office for treatment.

Although complexity, vulnerability and age may not predispose older persons to receive poorerquality care, several studies provide evidence that patients whose care requires time-consuming processes such as history taking, counseling, and medication-prescribing do experience inadequate quality of care. Min et al. (71) found that only about 30 percent of vulnerable older people receive adequate counseling and history taking. Simon et al. (101) found that 29 percent of elderly HMO patients receive at least one potentially inappropriate drug. Lin (2004) found that potentially harmful drug interactions occur in as many as 50 percent of patients taking over five medications a day. Moreover, patients with high medical costs tend to lack trust in their physicians and have more negative assessments of the quality of the care they receive (33).

The real-world experience of health care provider organizations supports the findings of a number of research studies, which suggest care management may be a delivery innovation that can reduce costs while enhancing the quality of care for people with complex health care needs. Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aim of improving patients' health status and reducing the need for medical services.

This synthesis looks at the evidence and explores the potential for care management to improve quality of care and reduce costs for people with complex health care needs. This synthesis addresses the following questions:

1. What is care management? 2. How are patients identified for care management programs? 3. Do research-based care management programs enhance quality and reduce costs for

patients with complex health care needs? 4. What are the characteristics of successful care management programs? 5. How have research-based care management programs been adapted to real-world

treatment settings? 6. How do payment policies influence the creation and success of care management programs?

People with complex health care needs are not a distinct category of patients; they are patients at the far end of a population-wide spectrum ranging from healthy individuals to people with serious medical problems and high utilization of health care services. This synthesis focuses on the most prevalent high-cost patients -- those with multiple chronic conditions, many medications, multiple providers, frequent hospitalizations, and limitations on their ability to perform basic daily functions.

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Methodology overview

Health services research on care management is difficult because care management interventions are operator-dependent, poorly standardized, of varying intensities, and have short follow-up periods. The patients enrolled in these studies may not be representative of real-world populations, the studies may not be applicable to different health care institutions, and the interventions may be more rigorously applied in a study situation than in the less controlled real world of medical practice. To try to bridge this gap, this synthesis reviewed the literature on care management for patients with complex health care needs and included interviews with leaders from health care organizations that have implemented programs for complex patients. Literature prior to 1990 was excluded as was literature discussing single chronic conditions such as diabetes or asthma. A notable exception: The leading congestive heart failure care management studies were included because they were performed with heart failure patients who also had multiple comorbidities and frequent hospitalizations. Literature using a purely pre-post design with no controls and literature describing care management programs in nations other than the United States and Canada were also excluded. Additional detail on methodological issues can be found in Appendix II.

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Findings

What is care management?

Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aim of improving patients' health status and reducing the need for medical services. The goals of care management are to improve patients' functional health status, enhance coordination of care, eliminate duplication of services, and reduce the need for expensive medical services (18).

Although both academic and commercial literature often use the terms "care management" and "case management" interchangeably, even within the same document, distinctions can be made. For example, case management often refers to a limited set of episodic services assisting patients and families in navigating the health care and social service systems with cost reduction as its primary goal. In contrast, care management is a broad set of longer-term services that includes medical management and assistance in navigating the system, with both quality enhancement and cost reduction as goals. Care management requires the involvement of professionals with clinical training, usually registered nurses (RNs).

Care management can also be contrasted with disease management and population management (Table 1). Disease management tends to target one disease, while care management focuses on individuals who often have multiple chronic conditions. Population management emphasizes care and prevention required to improve the health of populations rather than of individuals, which requires stratifying the population into different risk groups depending on disease severity and choosing the best approach for each risk group (115).

Table 1: Concepts of chronic disease management

Disease management Care management Population management

Focus on specific diseases

Focus on specific patients who often have multiple diseases

Focus on a large population of patients, risk-stratifying the population to determine the best approach to each risk subgroup

These terms are best understood through a historical trajectory. In the 1990s, chronic disease appeared on the radar screens of health policy experts. Two schools of thought emerged about how to improve care and reduce costs for this large population. One was primary-care-based, the other carved out disease management as a service separate from primary care. The primarycare-based approach was codified into the Chronic Care Model, developed by Ed Wagner and associates in the late 1990s (8). The carve-out approach generally was used by for-profit disease management companies that obtained contracts with health plans by agreeing to reduce health plan costs. The implementation of both approaches tended to emphasize specific chronic conditions such as diabetes, asthma and congestive heart failure. Research about patients with multiple chronic conditions was very limited (8, 20).

In the last decade, far more attention has been focused on patients with complex health care needs. Prominent researchers demonstrated that comorbidity in patients with chronic conditions was the rule rather than the exception (104). An intellectual shift gathered momentum, moving from a focus on single chronic conditions to multiple comorbid conditions -- a shift from diseasecenteredness to patient-centeredness, from disease management to care management. As part of this shift, population-wide risk stratification assumed a central role in health care thinking, with the stratification emphasizing patients' risk of incurring high costs, particularly hospitalization.

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