Success Factors for Evidence-Based Care Management of Patients with Severe or Multiple Chronic Conditions

 

Private and public health care purchasers are under extra pressure to stem health care costs for the patients who account for the most health care expenses: Those with severe or multiple chronic conditions. In the US, approximately 10% of patients account for 70% of total health care expenditures—with many of these costs related to avoidable hospitalization. Care management of these patients is a challenge because they are frequently seeing multiple health care providers, taking numerous medications and often coping with overwhelming self-care demands. A recent article by Thomas Bodenheimer, MD and Rachel Berry-Millet in the New England Journal of Medicine summarizes the evidence on care management approaches. The article details success factors for using care management to improve quality and cost outcomes for patients with multiple or complex conditions. These authors define care management as “a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating duplication of services, and reducing the need for expensive medical services.”

Bodenheimer’s and Berry-Millet’s review of the literature finds that care management can indeed be an effective approach for improving care quality and reducing care costs. However, not all care management programs are effective. The following is a summary of six recommendations based on these author's thorough review of the care management research literature:

1. Reserve Care Management for Patients Who Can Benefit Most

Because of the intensity and cost involved, care management should be reserved for patients with complex care needs who are at high risk of costly care. However, patients “who are too sick to benefit” are generally not appropriate candidates for care management.

2. Use Predictive Modeling Tools to Identify Candidates for Care Management

Predictive modeling tools and technologies should be used to identify patients who can benefit most from care management. Models that factor in diagnostic and medication information are more effective at predicting future costs than models that simply measure past costs.

3. Train Care Managers in Chronic Care & Self-Care Support

Care management is most effective if delivered by nurses and nurse practitioners who have been formally trained in chronic care management. Training in interventions for supporting patient and family member engagement and activation is also essential.

4. Combine Hospital Discharge Planning With Care Management

Hospital discharge planning, without care management, is not effective. These authors note, “the success of these two interventions in reducing re-admissions depends on the employment of well-trained care managers and the extension of care management into the home.”

5. Change Payment Policies for Hospital Care

If hospitals continue to profit from avoidable hospitalizations there will be no incentive to develop effective hospital to home care management programs. Payment policies must align with quality and cost goals.

6. Address Nurse Shortages & Build Nurse Care Management Competencies

The workforce supply and readiness issue must be addressed. According to these authors “nursing shortages and the paucity of training programs for nurses to become effective care managers” are leading barriers to better quality and cost outcomes in health care.

 

 

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