Intensive care management of a complex Medicaid population: a randomized evaluation

Rowe, Jack S; Gulla, Joy; Vienneau, Maryann; Nussbaum, Lisa; Maher, Erin J.; Mendu, Mallika L.; Tishler, Lori Wiviott; Weil, Éric; Chaguturu, Sreekanth K.; Vogeli, Christine

doi:10.37765/ajmc.2022.89219

Cited by 6 publications

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“…In contrast, the Integrated Care Management Program (iCMP), our system’s longest-running care management program, provides longitudinal care management for months to years for patients with complex conditions via primary care practice-embedded staff . The most complex 1% of patients in our system are escalated to the iCMP PLUS program, an intensive version of iCMP that partners with an external nonprofit to provide services in home- and community-based settings . We have also developed programs for specific complex medical situations associated with both increased utilization and patient-level needs (eg, end-stage kidney disease, end-of-life care).…”

Section: Discussionmentioning

confidence: 99%

“…Specifically, most programs in this continuum have demonstrated statistically significant effects on clinical outcomes and/or utilization (Table 2). Taking a comprehensive approach to evaluations, we evaluate cost and utilization but also assess broader measures, eg, connections to primary care and the staff-patient experience.…”

Section: Discussionmentioning

confidence: 99%

“…10,13 The most complex 1% of patients in our system are escalated to the iCMP PLUS program, an intensive version of iCMP that partners with an external nonprofit to provide services in home-and community-based settings. 14 We have also developed programs for specific complex medical situations associated with both increased utilization and patient-level needs (eg, end-stage kidney disease, 15 end-of-life care).…”

Section: Table 2)mentioning

confidence: 99%

“…The spectrum of care management programs at Mass General Brigham, organized along 3 dimensions: level of patient complexity/risk (x-axis), the length of time that a patient is anticipated to need care management (y-axis), and the primary site of care (in color). Specifically, most programs in this continuum have demonstrated statistically significant effects on clinical outcomes and/or utilization (Table 2 [10][11][12][13][14][15] ). Taking a comprehensive approach to evaluations, we evaluate cost and utilization but also assess broader measures, eg, connections to primary care and the staff-patient experience.…”

Section: Table 2)mentioning

confidence: 99%

“…Outcomes: More transplant referrals (59% vs 20%; higher transplant rates (11% vs 3%) vs ESKD patients nationally iCMP PLUS Delivered through a contract with an external nonprofit, this program targets the highest-complexity patients in our system and delivers care via nurse practitioners in home and community settings Mo-y Study: randomized study (PLUS vs standard iCMP); patients insured by mix of payers 14 Outcomes: TME reduction $1827 PMPM (P = .08); 66% decrease in rate of ED observation stays (P = .01)…”

Section: Mo-ymentioning

confidence: 99%

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Reframing Value-Based Care Management

et al. 2023

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ImportanceCare management programs are increasingly being utilized by health systems as a new foundational strategy to advance value-based care. These programs offer the promise of improving patient outcomes while decreasing health care utilization and costs. However, as these programs proliferate in number and specialization, the field of care management is increasingly at risk of fragmentation, inefficiency, and failure to meet the core needs of the patient.ObservationsThis review of the current state of care management identifies several key challenges for the field, including an unclear value proposition, a focus on system- vs patient-centered outcomes, increased specialization by private and public entrants that produces care fragmentation, and lack of coordination among health and social service entities. A framework is proposed for reorienting care management to truly address the needs of patients through acknowledging the dynamic nature of patient care needs, providing a continuum of need-targeted programming, coordinating care among all involved entities and staff, and performing regular evaluations of outcomes that include patient-centered and health equity measures. Guidance on how this framework can be implemented within a health system and an outline of recommendations is provided for how policymakers may incentivize the development of high value and more equitable care management programs.Conclusions and RelevanceWith increased focus on care management as a cornerstone of value-based care, value-based health leaders and policymakers can improve the effectiveness and value of care management programs, reduce patient financial burden for care management services, and promote stakeholder coordination.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Table 2)mentioning

confidence: 99%

Section: Table 2)mentioning

confidence: 99%

Section: Mo-ymentioning

confidence: 99%

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Reframing Value-Based Care Management

et al. 2023

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Hospital Readmissions by Variation in Engagement in the Health Care Hotspotting Trial

Yang,

Wiest,

Davis

et al. 2023

JAMA Netw Open

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ImportanceVariability in intervention participation within care management programs can complicate standard analysis strategies.ObjectiveTo evaluate whether care management was associated with reduced hospital readmissions among individuals with higher participation probabilities.Design, Setting, and ParticipantsA total of 800 hospitalized patients aged 18 years and older were randomized as part of the Health Care Hotspotting randomized clinical trial, which was conducted in Camden, New Jersey, from June 2014 to September 2017. Data were collected through October 2018. In this new analysis performed between April 6, 2022, and April 23, 2023, the distillation method was applied to account for variable intervention participation. A gradient-boosting machine learning model produced predicted probabilities of engaged participation using baseline covariates only. Predicted probabilities were used to trim both intervention and control populations in an equivalent manner, and intervention effects were reevaluated within study population subsets that were increasingly concentrated with patients having higher participation probabilities. Patients had 2 or more hospitalizations in the 6-month preenrollment period and documented evidence of chronic illness and social complexity.InterventionMultidisciplinary teams provided services to patients in the intervention arm for a mean 120 days after hospital discharge. Patients in the control group received usual postdischarge care.Main Outcomes and MeasuresHospital readmission rates and counts 30, 90, and 180 days postdischarge.ResultsOf 800 eligible patients, 782 had complete discharge information and were included in this analysis (mean [SD] age, 56.6 [12.7] years; 395 [50.5%] female). In the intent-to-treat analysis, the unadjusted 180-day readmission rate for treatment and control groups was 60.1% vs 61.7% (adjusted odds ratio, 0.95; 95% CI, 0.71-1.28; P = .73) and the mean (SD) number of 180-day readmissions was 1.45 (1.89) vs 1.48 (1.94) (adjusted incidence rate ratio, 0.99, 95% CI, 0.88-1.12; P = .86). Among the population with the highest participation probabilities, the mean (SD) 180-day readmission count was 1.22 (1.74) vs 1.57 (1.74) and the incidence rate ratio attained statistical significance (adjusted incidence rate ratio, 0.74; 95% CI, 0.56-0.99; P = .045). Adjusted odds ratios and adjusted incidence rate ratios for 30- and 90-day outcomes reached statistical significance after population distillation.Conclusions and RelevanceThis secondary analysis of a randomized clinical trial found that care management was associated with reduced readmissions among patients with higher participation probabilities, suggesting that program operation could be improved by addressing barriers to participation and refining inclusion criteria to identify patients most likely to benefit.Trial RegistrationClinicalTrials.gov Identifier: NCT02090426

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Social Risks and Health Care Use in Medically Complex Patients

Tucher,

Steele,

Uratsu

et al. 2024

JAMA Netw Open

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ImportanceIntegrated health care systems have initiated major investments to identify and address social risks, particularly for patients with multiple medical conditions.ObjectiveTo evaluate the association of social risks with health care use among patients with complex multimorbidity.Design, Setting, and ParticipantsThis longitudinal cohort study assessed Kaiser Permanente Northern California (KPNC) patients with (1) moderate medical complexity (defined by high comorbidity score, high risk of hospitalization, and/or prior emergency department [ED] admissions) and (2) high medical complexity (eg, meeting additional criteria, such as ≥7 medications and laboratory evidence of poor disease control).ExposureSocial risks (eg, requiring medical financial assistance and self-reported social barriers to care).Main Outcomes and MeasuresInpatient and outpatient health care use during 12 months of follow-up (January 15, 2023, to January 14, 2024).ResultsThe sample included 97 252 KPNC patients (mean [SD] age, 69.5 [16] years; 52.1% female; 10.6% Asian, 11.1% Black, 18.3% Hispanic, 54.6% White, and 5.5% other race or ethnicity [eg, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, multiracial, or unknown race]; and 8.8% insured by Medicaid), including 27 827 with moderate medical complexity (5074 [18.2%] with social risks) and 69 425 with high medical complexity (17 343 [25.0%] with social risks). In fully adjusted models, for moderate medical complexity, social risks were associated with higher odds of inpatient admissions (odds ratio [OR], 1.2; 95% CI, 1.1-1.4), ED visits (OR, 1.2; 95% CI, 1.1-1.3), and mental health visits (OR, 1.2; 95% CI, 1.1-1.3) vs individuals without social risks. Among individuals with high medical complexity, social risks were associated with higher odds of inpatient admissions (OR, 1.2; 95% CI, 1.1-1.2), ED visits (OR, 1.2; 95% CI, 1.1-1.2), and 30-day readmissions (OR, 1.2; 95% CI, 1.1-1.3) and higher odds of mental health visits (OR, 1.3; 95% CI, 1.2-1.3) vs individuals without social risks.Conclusions and relevanceIn this cohort study of individuals with medical complexity, coexisting social risks were associated with substantial downstream health care use. Efforts to reduce use in individuals with complex medical comorbidity could include concurrent efforts to identify and reduce social risks.

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Intensive care management of a complex Medicaid population: a randomized evaluation

Cited by 6 publications

References 0 publications

Reframing Value-Based Care Management

Reframing Value-Based Care Management

Hospital Readmissions by Variation in Engagement in the Health Care Hotspotting Trial

Social Risks and Health Care Use in Medically Complex Patients

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