Transitional Care Models for High-Need, High-Cost Adults in the United States

Abstract

Purpose of Study: This scoping review explored research literature on the integration and coordination of services for high-need, high-cost (HNHC) patients in an attempt to answer the following questions: What models of transitional care are utilized to manage HNHC patients in the United States? and How effective are they in reducing low-value utilization and in improving continuity? Primary Practice Settings: U.S. urban, suburban, and rural health care sites within primary care, veterans' services, behavioral health, and palliative care. Methodology and Sample: Utilizing the Joanna Briggs Institute and PRISMA guidelines for scoping reviews, a stepwise method was applied to search multiple databases for peer-reviewed published research on transitional care models serving HNHC adult patients in the United States from 2008 to 2018. All eligible studies were included regardless of quality rating. Exclusions were foreign models, studies published prior to 2008, review articles, care reports, and studies with participants younger than 18 years. The search returned 1,088 studies, of which 19 were included. Results: Four studies were randomized controlled trials and other designs included case reports and observational, quasi-experimental, cohort, and descriptive studies. Studies focused on Medicaid, Medicare, dual-eligible patients, veterans, and the uninsured or underinsured. High-need, high-cost patients were identified on the basis of prior utilization patterns of inpatient and emergency department visits, high cost, multiple chronic medical diagnoses, or a combination of these factors. Tools used to identify these patients included the hierarchical condition category predictive model, the Elder Risk Assessment, and the 4-year prognostic index score. The majority of studies combined characteristics of multiple case management models with varying levels of impact. Implications for Case Management Practice:

Frailty and Determinants of Health Among Older Adults in the United States 2011–2016

“…Use of telehealth for case management and care coordination in US rural settings is receiving increased policy emphasis due to older adults’ higher rates of poverty, chronic conditions, and age-adjusted mortality for all causes in these settings, particularly during COVID-19 (Department of Health and Human Services, 2020; National Academies of Sciences, Engineering, and Medicine, 2021; National Advisory Committee on Rural Health and Human Services, 2019). Nursing care management models such as the Transitional Care Model (Assessing/Managing Risks and Symptoms) may be able to incorporate modified Fried screening to better monitor older adult symptoms to prevent poor functional outcomes across a wide range of rural and urban clinical settings and health system care model designs to achieve improved health equity outcomes (Hewner et al, 2021; Hirschman et al, 2015; National Academies of Medicine, 2017; National Academies of Sciences, Engineering, and Medicine, 2021).…”

Care Coordination: A Concept Analysis

“…16 Many models focus on care coordinators' efforts to stabilize care transitions in populations that have highrisk conditions, such as congestive heart failure, or in complex patients during major care transitions between organizations, such those occurring between hospitals and skilled nursing facilities. 17 Other care transition models focus primarily on harnessing transitional data for the purpose of cross-agency communication in the form of care alerts. 5 2) "In partnership with other healthcare professionals, registered nurses have demonstrated leadership and innovation in the design, implementation, and evaluation of successful team-based care coordination processes and models.…”

Identifying patterns of clinical conditions among high-cost older adult health care users using claims data: a latent class approach

“…Previous studies have supported the segmentation of high-cost health care users on the basis of prior healthcare utilization patterns [ 7 ], complex medical conditions [ 9 ], high cost [ 10 ], or a combination of these factors [ 11 ]. A concept analysis identified three main subgroups of high-cost health care users: adults with multiple chronic conditions and functional disability, the frail elderly, and patients under 65 years old with behavioral health condition or disabled [ 12 ].…”

“…A concept analysis identified three main subgroups of high-cost health care users: adults with multiple chronic conditions and functional disability, the frail elderly, and patients under 65 years old with behavioral health condition or disabled [ 12 ]. Another scoping review and gap analysis focused on transitional care models for high-need, high-cost adults to reduce low-value utilization [ 11 ]. Figueroa et al [ 13 ] identified two high-need, high-cost patient personas across 11 developed countries, using accessible patient-level datasets.…”

“…Another recognized limitation of current research involves population identification [ 16 ]. Although the terminologies of “high-need” and “high-cost” are often used alternatively [ 11 , 13 , 17 ], high-need patients are often emphasized to target care [ 16 ], as they represent a diverse group with high burden of medical comorbidities, social complexity, functional limitations, and disability [ 18 ]. The definition of high-cost patients using health care-related expenditures may inform policy makers to optimize health policies to combat increasing medical spending.…”