Effectiveness of Outpatient Case Management for Adults With Medical Illness and Complex Care Needs

1
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

2
Outline of Material

• 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

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

3
BackgroundChronic Illness Care and Case
Management

• 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 patients 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.

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

4
Background Functions of a Case Manager

• 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

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

5
Background Roles of a Case Manager Within a
Health Care Organization

• 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

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

6
Background Challenges Related to Evaluating the
Effectiveness of Case Management Programs

• 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.

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

7
Addressing the Challenges Related to Evaluating
the Case Management Programs in This Review

• 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

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

8
Agency for Healthcare Research and Quality (AHRQ)
Comparative Effectiveness Review (CER) Development

• 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-managemen
  t.cfm.

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

9
Clinical Questions Addressed by This Comparative
Effectiveness Review (1 of 2)

• Key Question 1. In adults with chronic medical
  illnesses and complex care needs, is case
  management effective in improving
• Patient-centered outcomes, including mortality,
  quality of life, disease-specific health
  outcomes, avoidance of nursing home placement,
  and patient satisfaction with care?
• 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?
• 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)?

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

10
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.

11
Rating the Strength of Evidence From the
Comparative Effectiveness Review

• The strength of evidence was classified into four
  broad categories

High Further research is very unlikely to change the confidence in the estimate of effect.
Moderate Further research may change the confidence in the estimate of effect and may change the estimate.
Low Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.
Insufficient Evidence either is unavailable or does not permit a conclusion.

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

12
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Multiple
Chronic Illnesses (1 of 2)

• 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

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

13
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Multiple
Chronic Illnesses (2 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

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

14
Evidence for the Effectiveness of Case Management
Programs That Serve Frail Elderly Patients

• 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

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

15
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Dementia (1 of
2)

• 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

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

16
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Dementia (2 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

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

17
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Congestive
Heart Failure (1 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

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

18
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Congestive
Heart Failure (2 of 2)

• Clinical Outcomes
• Case management programs improved quality of life
  but did not affect mortality.
• Strength of Evidence Low

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

19
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Diabetes

• 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

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

20
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Serious Chronic
Infections

• 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

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

21
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Cancer (1 of 2)

• 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 protocols
• Strength of Evidence Low

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

22
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Cancer (2 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???

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

23
Evidence for the Effectiveness of Case Management
Programs That Serve Patients With Other Clinical
Conditions

• 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??????

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

24
Additional Information

• Based on the range of interventions reviewed, the
  types of patients who potentially could benefit
  from case management include
• Patients with life-threatening chronic
  diseasessuch as congestive heart failure or HIV
  infectionthat can be improved with proper
  treatment
• Patients with progressive, debilitating, and
  often irreversible diseasessuch as dementia or
  multiple chronic diseases in the agedfor 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

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

25
Conclusions (1 of 3)

• 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).

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

26
Conclusions (2 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.

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

27
Conclusions (3 of 3)

• 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

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

28
Gaps in Knowledge (1 of 3)

• 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

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

29
Gaps in Knowledge (2 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.

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

30
Gaps in Knowledge (3 of 3)

• Other elements of case management that should be
  explicitly described in future research include
• Experience level of case managers
• Training received by case managers
• Specific functions of case managers and the
  distribution of effort devoted to different
  activities
• Use of protocols, guidelines, and information
  technology
• Modes of patient contact
• Average caseload??
• Relationship to other health care providers

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

31
What To Discuss With Your Patients andTheir
Caregivers (1 of 3)

• What case management (CM) is and that the option
  of involving a case manager in the management of
  the patients medical condition might exist,
  depending on the patients 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 patients
  health care team, although the level of
  interaction might vary depending on the type of
  CM program available to the patient

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

32
What To Discuss With Your Patients andTheir
Caregivers (2 of 3)

• That a case manager can be an advocate who
  evaluates the patients needs and works to
  surmount problems with access to clinical
  services
• How case management might affect the patients
  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)

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

33
What To Discuss With Your Patients andTheir
Caregivers (3 of 3)

• 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 patients 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)

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