Cost Analysis of the Geriatric Resources for Assessment and Care of Elders Care Management Intervention

Counsell, Steve; Callahan, Christopher M.; Tu, Wanzhu; Stump, Timothy E.; Arling, Gregory

doi:10.1111/j.1532-5415.2009.02383.x

Cited by 134 publications

(143 citation statements)

References 24 publications

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“…For example, during the second year of a two-year, cluster-randomized trial, the more intensive GRACE (Geriatric Resources for Assessment and Care of Elders) model significantly reduced hospital admissions and emergency department visits (but did not affect overall health care costs) among high-risk, low-income seniors. 7,8 Similarly, recent studies of other primary care-based interventions for high-risk patients have reported significant improvement in one or two, but not all three, of the components of "the triple aim:" quality of care, health, and health care costs. 12,33 High-quality studies of various versions of the "patient-centered medical home" have shown improvement in the quality of care or in some clinical outcomes, but none has shown a significant reduction in net health care costs.…”

Section: Discussionmentioning

confidence: 99%

“…In the meantime, however, as millions of baby-boomers are reaching retirement age each year, near-term improvements may be achievable by developing and adopting clinical models that improve outcomes for high-risk people with multiple chronic conditions. Some such models have shown promise, [7][8][9][10][11][12] while others have either failed 13 or have not yet been tested rigorously. 14 Guided Care is a new model of comprehensive, interdisciplinary care that comprises primary care-based care management, transitional care, and support for self-management and family caregiving.…”

Section: Introductionmentioning

confidence: 99%

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A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

et al. 2013

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BACKGROUND: Patients at risk for generating high health care expenditures often receive fragmented, lowquality, inefficient health care. Guided Care is designed to provide proactive, coordinated, comprehensive care for such patients. OBJECTIVE: We hypothesized that Guided Care, compared to usual care, produces better functional health and quality of care, while reducing the use of expensive health services. DESIGN: 32-month, single-blind, matched-pair, cluster-randomized controlled trial of Guided Care, conducted in eight community-based primary care practices. PATIENTS: The "Hierarchical Condition Category" (HCC) predictive model was used to identify high-risk older patients who were insured by fee-for-service Medicare, a Medicare Advantage plan or Tricare. Patients with HCC scores in the highest quartile (at risk for generating high health care expenditures during the coming year) were eligible to participate. INTERVENTION: A registered nurse collaborated with two to five primary care physicians in providing eight services to participants: comprehensive assessment, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for selfmanagement, caregiver support, and access to community-based services. MAIN MEASURES: Functional health was measured using the Short Form-36. Quality of care and health services utilization were measured using the Patient Assessment of Chronic Illness Care and health insurance claims, respectively. KEY RESULTS: Of the eligible patients, 904 (37.8 %) gave written consent to participate; of these, 477 (52.8 %) completed the final interview, and 848 (93.8 %) provided complete claims data. In intention-to-treat analyses, Guided Care did not significantly improve participants' functional health, but it was associated with significantly higher participant ratings of the quality of care (difference=0.27, 95 % CI=0.08-0.45) and 29 % lower use of home care (95 % CI=3-48 %). CONCLUSIONS: Guided Care improves high-risk older patients' ratings of the quality of their care, and it reduces their use of home care, but it does not appear to improve their functional health.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

et al. 2013

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“…3 Among the six studies meeting their evidence standards and including at least three of five PCMH characteristics while measuring triple aim, patient or professional experience outcomes, findings included only one report of significant cost savings. 4 Others reported increased costs, 5 and suggestive but inconclusive cost savings. 6,7 Half of the studies reported significant and positive reductions in hospital use, 5,8,9 while half reported suggestive but inconclusive findings.…”

Section: Introductionmentioning

confidence: 99%

Quality and Efficiency in Small Practices Transitioning to Patient Centered Medical Homes: A Randomized Trial

et al. 2013

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BACKGROUND: There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition. OBJECTIVE: Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices. KEY RESULTS: Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p= 0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control −0.4 percentage points, p= 0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention −0.7 percentage points, control+0.5 percentage points, p=0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures. CONCLUSIONS: In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.

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“…10 A few care coordination programs have shown favorable effects, but each program was tested within a single health care system with small samples, which raises questions about the generalizability of the findings to other settings. [11][12][13] Furthermore, impacts of these programs were identified only for high-risk subsets of enrolled patients. Transitional care programs have generated major reductions in readmissions for people recently discharged from a hospital.…”

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confidence: 99%

Six Features Of Medicare Coordinated Care Demonstration Programs That Cut Hospital Admissions Of High-Risk Patients

et al. 2012

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As policy makers seek to slow the growth in Medicare spending, they have appropriately focused attention on beneficiaries with multiple chronic conditions. Many care coordination and disease management programs designed to improve beneficiaries' care and reduce their need for hospitalizations have been tested, but few have been successful. This study, however, found that four of eleven programs that were part of the Medicare Coordinated Care Demonstration reduced hospitalizations by 8-33 percent among enrollees who had a high risk of near-term hospitalization. The six approaches practiced by care coordinators in at least three of the four programs were as follows: supplementing telephone calls to patients with frequent in-person meetings; occasionally meeting in person with providers; acting as a communications hub for providers; delivering evidence-based education to patients; providing strong medication management; and providing timely and comprehensive transitional care after hospitalizations. When care management fees were included, the programs were essentially costneutral, but none of these programs generated net savings to Medicare. Our results suggest that incorporating these approaches into medical homes, accountable care organizations, and other policy initiatives could reduce hospitalizations and improve patients' lives. However, the approaches would save money only if care coordination fees were modest and organizations found cost-effective ways to deliver the interventions. M edicare's rapidly increasing costs have led policy makers to focus on improving the coordination of care for people with high-cost chronic conditions, for several reasons. First, beneficiaries with such conditions account for a disproportionately large share of total Medicare spending. 1 Second, ample opportunities exist to improve the care they receive.2-4 Studies of care coordination have noted the high proportion of preventable hospitalizations arising from inadequate or inappropriate care, poor patient adherence to recommended medication and selfcare regimens, and poor communication among the many providers whom a patient with chronic conditions typically sees. 2-9Despite the apparent opportunity to control spending by reducing the need for hospitalizations among such beneficiaries, several demonstrations by the Centers for Medicare and Medicaid Services (CMS) to test disease management and care coordination programs in fee-forservice Medicare have been largely unsuccessful. 8,9 Most of these unsuccessful programs are telephone-only interventions that develop and update care plans to meet patients' needs, educate patients about self-care and medication

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Cost Analysis of the Geriatric Resources for Assessment and Care of Elders Care Management Intervention

Cited by 134 publications

References 24 publications

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

Quality and Efficiency in Small Practices Transitioning to Patient Centered Medical Homes: A Randomized Trial

Six Features Of Medicare Coordinated Care Demonstration Programs That Cut Hospital Admissions Of High-Risk Patients

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