effectiveness of outpatient case management for adults with medical illness and complex care needs

Effectiveness of Outpatient Case Management for Adults With

Medical Illness and Complex Care Needs

Prepared for:Agency for Healthcare Research and Quality (AHRQ)

www.ahrq.gov

Introduction to case management (CM) programs and the conditions they target

Systematic review methods The clinical questions addressed by the

comparative effectiveness review Results of studies and evidence-based conclusions

about the effectiveness of CM programs for patients with chronic conditions and complex care needs

Gaps in knowledge and future research needs What to discuss with patients and their caregivers

Outline of Material

Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99.Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Chronic diseases are the leading cause of illness, disability, and death in the United States.

For patients with chronic illnesses, health care resources generally are available but may be inaccessible or poorly coordinated.

One strategy for improving the effectiveness of care for chronic illnesses is to develop programs that enhance coordination and implementation of care plans.

Case management is one such service in which a person, usually a nurse or social worker, coordinates and implements a patient’s care plan. The case manager might work alone or in conjunction with a team of health

professionals. The evolution of care models in health care has led to the use of

the term “case management” to describe a wide variety of interventions.

Background:Chronic Illness Care and Case Management


In chronic illness care, while clinical functions are central to the role of a case manager, he or she also performs coordinating functions.

Clinical functions of a case manager include: Disease-oriented assessment and monitoring Medication adjustment Health education Self-care instructions

The distinct but complementary coordinating functions performed by a case manager include: Helping patients navigate health care systems Connecting patients with community resources Orchestrating multiple facets of health care delivery Assisting with administrative and logistical tasks

Background: Functions of a Case Manager


Depending on the health care organization, the case manager can play distinctly different roles: A care provider who helps patients to improve their self-

management skills and/or helps caregivers to be more effective in supporting patients

A collaborative member of the care delivery team who promotes better communication with providers and advocates for implementation of care plans

A patient advocate who evaluates patient needs and works to surmount problems with access to clinical services

Background: Roles of a Case Manager Within a Health Care Organization


Individual case management (CM) programs are often customized for the clinical issues of the population they serve. A CM program for homeless people with AIDS has a different

mix of activities than a program for patients with dementia and their caregivers.

Some CM programs target patients with specific characteristics, while others serve unselected populations with a chronic illness.

CM interventions may be intensive and involve frequent contact or may entail only infrequent contact.

This variability in CM interventions makes evaluation of the effectiveness of CM programs challenging.

Background: Challenges Related to Evaluating the Effectiveness of Case Management Programs


Given the substantial heterogeneity of purposes, approaches, and populations within the broad category of case management (CM) programs, the scope of this review was limited in several ways including: Inclusion of CM programs where case managers had a

combination of clinical and coordinating functions Inclusion of CM programs that targeted chronic medical

illnesses only Restriction of the review to CM programs that involved a

sustained relationship between the case manager and patient

Evaluation of patients in outpatient settings only

Addressing the Challenges Related to Evaluating the Case Management Programs in This Review


Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others.

A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment.

The results of these reviews are summarized into Clinician Research Summaries and Consumer Research Summaries for use in decisionmaking and in discussions with patients. The Research Summaries and the full report, with references for included and excluded studies, are available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review (CER) Development


Key Question 1. In adults with chronic medical illnesses and complex care needs, is case management effective in improving:a. Patient-centered outcomes, including mortality, quality of life,

disease-specific health outcomes, avoidance of nursing home placement, and patient satisfaction with care?

b. Quality of care, as indicated by disease-specific process measures, receipt of recommended health care services, adherence to therapy, missed appointments, patient self-management, and changes in health behavior?

c. Resource utilization, including overall financial cost, hospitalization rates, days in the hospital, emergency department use, and number of clinic visits (including primary care and other provider visits)?

Clinical Questions Addressed by This Comparative Effectiveness Review (1 of 2)


Clinical Questions Addressed by This Comparative Effectiveness Review (2 of 2)

Key Question 2. Does the effectiveness of case management differ according to patient characteristics, including but not limited to: particular medical conditions, number or type of comorbidities, patient age and socioeconomic status, social support, and/or level of formally assessed health risk?

Key Question 3. Does the effectiveness of case management differ according to intervention characteristics, including but not limited to practice or health care system setting; case manager experience, training, or skills; case management intensity, duration, and integration with other care providers; and the specific functions performed by case managers?Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99.Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

The strength of evidence was classified into four broad categories:

Rating the Strength of Evidence From the Comparative Effectiveness Review


Patient Experience Outcomes CM programs increased the perception of patients

that their care was better coordinated.˜Strength of Evidence: High

Clinical Outcomes CM programs did not improve functional status or

overall mortality.Strength of Evidence: High

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Multiple Chronic Illnesses (1 of 2)


Resource Utilization Outcomes Case management (CM) programs did not reduce overall

hospitalization rates.Strength of Evidence: Moderate CM programs were more effective for preventing

hospitalizations when case managers had greater personal contact with patients and physicians.

Strength of Evidence: Low CM programs were more effective for reducing

hospitalization rates among patients with greater disease burden.

Strength of Evidence: Low CM programs did not reduce Medicare expenditures.Strength of Evidence: High

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Multiple Chronic Illnesses (2 of 2)


Clinical Outcomes Case management (CM) programs did not affect

mortality.˜˜˜Strength of Evidence: Low

Resource Utilization CM programs did not reduce nursing home admissions or

acute hospitalizations.Strength of Evidence: Low

Evidence for the Effectiveness of Case Management Programs That Serve Frail Elderly Patients


Patient Experience Outcomes Case management (CM) programs reduced caregiver depression

at 2 years and caregiver burden at 12 months.Strength of Evidence: Moderate

Quality of Care Outcomes CM programs increased adherence to clinical guidelines for

dementia care when focused on those guidelines˜˜˜.Strength of Evidence: Low

Resource Utilization Outcomes CM programs did not result in reduction in health care

expenditures at 12 months.Strength of Evidence: Moderate

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Dementia (1 of 2)


Clinical Outcomes Case management (CM) programs delayed nursing home

placement of patients with dementia who have in-home spouse caregivers when program duration was longer than 2 years. ˜™™

Strength of Evidence: Low CM programs did not result in significant delays in nursing

home placement if the programs had a duration of 2 years or less. ˜˜™

Strength of Evidence: Moderate CM programs did not lower mortality rates.Strength of Evidence: High CM programs did not result in changes in the behavioral symptoms

of patients.Strength of Evidence: Moderate

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Dementia (2 of 2)


Patient Experience Outcomes Case management (CM) programs increased patient

satisfaction.Strength of Evidence: Moderate

Quality-of-Care Outcomes CM programs increased patient adherence to recommended

disease self-management behaviors.Strength of Evidence: Moderate

CM programs were more effective in improving patient outcomes when case managers were a part of a multidisciplinary team of health care providers.

Strength of Evidence: Low

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Congestive Heart Failure (1 of 2)


Clinical Outcomes Case management programs improved quality of life

but did not affect mortality.Strength of Evidence: Low

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Congestive Heart Failure (2 of 2)


Clinical Outcomes Case management (CM) programs improved glucose control.

Strength of Evidence: Low CM programs did not improve management of lipids or

weight/body mass index.Strength of Evidence: Moderate CM programs were not effective at reducing mortality.Strength of Evidence: Low

Resource Utilization Outcomes CM programs were not effective at reducing hospitalization

rates.Strength of Evidence: Low

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Diabetes


Quality-of-Care Outcomes Case management (CM) programs improved rates of

successful treatment for tuberculosis in vulnerable populations who were in short-term programs that emphasized medication adherence.

Strength of Evidence: Moderate Clinical Outcomes

CM programs did not improve survival among patients with HIV infection.

Strength of Evidence: Low

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Serious Chronic Infections


Patient Experience Outcomes Case management (CM) programs improved patient satisfaction

with care.Strength of Evidence: Moderate

Quality-of-Care Outcomes CM programs were effective in increasing the receipt of

appropriate (guideline-recommended) cancer treatment.Strength of Evidence: Moderate

CM programs were more effective when: The intensity and duration of the intervention was greater The program was integrated with patients’ usual care providers The interventions were structured through preintervention training and

care protocolsStrength of Evidence: Low

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Cancer (1 of 2)


Clinical Outcomes Case management (CM) programs were effective in

improving selected cancer-related symptoms and functioning (physical, psychosocial, and emotional) but did not improve overall quality of life or survival.Strength of Evidence: Low

Resource Utilization Outcomes CM programs had little effect on overall health care

utilization and cost of care.Strength of Evidence: Low„„„

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Cancer (2 of 2)


Resource Utilization Outcomes Case management programs reduced emergency

department visits among patients with chronic obstructive pulmonary disease and among homeless people.Strength of Evidence: Low„„„„„„

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Other Clinical Conditions


Based on the range of interventions reviewed, the types of patients who potentially could benefit from case management include: Patients with life-threatening chronic diseases—such as

congestive heart failure or HIV infection—that can be improved with proper treatment

Patients with progressive, debilitating, and often irreversible diseases—such as dementia or multiple chronic diseases in the aged—for which supportive care can enhance independence and quality of life

Patients with progressive chronic diseases (e.g., diabetes mellitus) for which self-management can improve health and functioning

Patients for whom serious social problems (e.g., homelessness) impair their ability to manage disease

Additional Information


Overall, the case-management interventions tested in the reviewed studies were associated with small changes in patient-centered outcomes, quality of care, and health care-resource utilization.

Specific findings of this review included: Case management tends to improve patient satisfaction

with care for some conditions (congestive heart failure [CHF] and cancer) and increase patient perception of care coordination (for multiple chronic illnesses).

Case management improves the quality of care, particularly for illnesses that require complex treatments (CHF, tuberculosis, and cancer).

Conclusions (1 of 3)


Other specific findings of this review included: For some medical conditions (congestive heart failure

and tuberculosis), case management improves patients’ medication adherence and self-management skills.

Case-management interventions showed mixed results in improving patients’ quality of life and functional status.

For the caregivers of patients with dementia, targeted case-management programs improve levels of stress, burden, and depression.



While low-level evidence suggested that case management can improve some types of health care utilization in patients with multiple chronic illnesses who have greater disease burden and chronic homelessness, the effects of case management on health care-resource utilization and on costs of care are minimal.

Low-level evidence also showed that case management produces better outcomes when it is characterized by: Intense programs with greater contact time Longer duration of interventions Integration of programs with patients’ usual care providers Incorporation of training protocols in the interventions



Published trials evaluating the effectiveness of case management (CM) in various patient populations have the following limitations:

A lack of effective risk-assessment tools for choosing candidates for CM to determine which patients achieve the greatest benefits from CM

A paucity of information on how the effectiveness of CM programs varies with patient characteristics

A lack of a uniform, consensus definition for CM A lack of comparisons of CM with other types of interventions

Gaps in Knowledge (1 of 3)


Other limitations in the trials evaluating the effectiveness of case management (CM) in various patient populations include: Little or no information about the extent to which CM

programs are integrated with the usual source of care Imprecision about the intensity of CM A lack of understanding of the correlation between CM

duration and benefits achieved

These limitations should be addressed in future studies of CM.



Other elements of case management that should be explicitly described in future research include:Experience level of case managersTraining received by case managersSpecific functions of case managers and the distribution of effort devoted to different activitiesUse of protocols, guidelines, and information technologyModes of patient contact Average caseload„„Relationship to other health care providers



What case management (CM) is and that the option of involving a case manager in the management of the patient’s medical condition might exist, depending on the patient’s specific medical condition(s) and health care plan

Whether the case manager will meet with the patient at his/her home, in your office, or by phone and the frequency of the meetings

The potential duration for which the case manager might work with the patient

That a case manager will work with the patient’s health care team, although the level of interaction might vary depending on the type of CM program available to the patient

What To Discuss With Your Patients andTheir Caregivers (1 of 3)


That a case manager can be an advocate who evaluates the patient’s needs and works to surmount problems with access to clinical services

How case management might affect the patient’s experience of care (patient satisfaction)

The available evidence for the effectiveness of case management in improving quality-of-care outcomes (such as receipt of guideline-recommended clinical services, medication adherence, and attending health care appointments)



The available evidence for the effectiveness of case management in improving patient-related outcomes (quality of life, ability to stay at home, and health-related outcomes such as mortality and disease symptoms) or caregiver outcomes (such as stress and depression), given the patient’s specific medical condition(s)

The available evidence for the effectiveness of case management in improving health care-resource utilization outcomes (such as hospitalization rates, health care costs, and physician and/or emergency department visits)



effectiveness of outpatient case management for adults with medical illness and complex care needs

Documents

effectiveness of care

health care resources

care provider

health care systems

chronic illness care

care delivery team

complex care needsgaps

complex care needsprepared