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The American Journal of Managed Care November 2017
Using the 4 Pillars to Increase Vaccination Among High-Risk Adults: Who Benefits?
Mary Patricia Nowalk, PhD, RD; Krissy K. Moehling, MPH; Song Zhang, MS; Jonathan M. Raviotta, MPH; Richard K. Zimmerman, MD, MPH; and Chyongchiou J. Lin, PhD
The Influence of Provider Characteristics and Market Forces on Response to Financial Incentives
Brock O’Neil, MD; Mark Tyson, MD; Amy J. Graves, SM, MPH; Daniel A. Barocas, MD, MPH; Sam S. Chang, MD, MBA; David F. Penson, MD, MPH; and Matthew J. Resnick, MD, MPH
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Patients' Perspectives of Care Management: A Qualitative Study
Ann S. O’Malley, MD, MPH; Deborah Peikes, PhD, MPA; Claire Wilson, PhD; Rachel Gaddes, MPH; Victoria Peebles, MSW; Timothy J. Day, MSPH; and Janel Jin, MSPH
Reframing the Unaffordability Debate: Patient Responsibility for Physician Care
Katherine Hempstead, PhD; Josh Gray, MBA; and Anna Zink, BA
Electronic Reminder's Role in Promoting Human Papillomavirus Vaccine Use
Jaeyong Bae, PhD; Eric W. Ford, PhD, MPH; Shannon Wu, BA; and Timothy Huerta, PhD, MS
Improving Antibiotic Stewardship: A Stepped-Wedge Cluster Randomized Trial
Adam L. Sharp, MD, MS; Yi R. Hu, MS; Ernest Shen, PhD; Richard Chen, MD; Ryan P. Radecki, MD, MS; Michael H. Kanter, MD; and Michael K. Gould, MD, MS
Changes in Cardiovascular Care Provision After the Affordable Care Act
Joseph A. Ladapo, MD, PhD; and Dave A. Chokshi, MD, MSc
Diabetes Care Improvement in Pharmacist- Versus Nurse-Supported Patient-Centered Medical Homes
Lillian Min, MD, MSHS; Christine T. Cigolle, MD, MS; Steven J. Bernstein, MD, MPH; Kathleen Ward, MPA; Tisha L. Moore, MPH; Jinkyung Ha, PhD; and Caroline S. Blaum, MD, MS
Validation of a Claims-Based Algorithm to Characterize Episodes of Care
Chad Ellimoottil, MD, MS; John D. Syrjamaki, MPH; Benedict Voit, MBA; Vinay Guduguntla, BS; David C. Miller, MD, MPH; and James M. Dupree, MD, MPH

Patients' Perspectives of Care Management: A Qualitative Study

Ann S. O’Malley, MD, MPH; Deborah Peikes, PhD, MPA; Claire Wilson, PhD; Rachel Gaddes, MPH; Victoria Peebles, MSW; Timothy J. Day, MSPH; and Janel Jin, MSPH
Risk-stratified care management is a cornerstone of patient-centered medical home models, but studies on patients’ perspectives of it are scarce. We explored patients’ experiences with care management, what they found useful, and what needs improvement.
Outreach from CPC practice care managers, health plans, and hospitals to patients at the time of hospital discharge contributed to patient confusion about the role each person played in their care and about who their care manager was. This duplicate outreach was an issue for approximately one-third of the patients with a hospitalization in the previous month. One patient who was confused about the identity of his care manager noted, “To be truthful, my Medicare supplements [supplementary insurance plan] has tried to take on the role of a care manager.” 

A few patients preferred not to interact with a care manager, particularly older patients who had a longstanding relationship with their primary care physician. One, for example, preferred to rely on her primary care physician of 20 years: “[He] is the one I can talk to the easiest. I am a firm believer in primary care doctors because I totally think that they are the ones who know a patient the best.”

Development of Care Plans 

CPC guidance to practices19 notes that an essential feature of care management is “a mutually agreed upon and documented plan of care, based on the patient’s goals and the best available medical evidence; it is accessible to all team members...and addresses all major and significant ongoing health problems and risks.” Although the initiative did not require practices to give patients a copy of their care plan, the patient’s involvement in goal setting was implicit in the CPC definition of a care plan. Few patients, however, had heard the terms “plan of care” or “care plan,” and many did not understand this concept even after we described it. After probing by the interviewers, about a quarter of the patients described formal care plans and goals (including steps for achieving them), which they had set with their physician and/or care manager. 

Patients varied widely in the degree to which they wanted to contribute to their care plan. About one-third of respondents mentioned that they were too old or sick to consider their goals or to develop such a plan and preferred to rely on their doctors’ opinion. Another one-fourth of respondents reported being very engaged in their care planning; of these, a handful had only recently become more engaged in their healthcare either because of failing health or their physician’s or care manager’s encouragement. The remainder of respondents did not understand the concept of care plans after we described it and thus could not comment on the extent to which they would want to contribute.

Only 1 patient reported having a copy of her care plan. Patients typically described a discussion or a verbal agreement with their primary care physician: “He didn’t write all that down. We just had a good discussion about my age, getting older, and stuff like that, and what I need to be aware of and start doing to help stay healthy.” For patients who could not articulate their goals and did not recall discussing them with their primary care physician or care manager, it is unclear whether someone in their practice created a care plan for them but did not share it or whether a plan was not created. 

Care Management Activities

Care managers communicated with patients primarily by phone and during office visits; a few used e-mail or text messaging. Patients who reported regular contact with a care manager said that they primarily received follow-up after hospitalizations, help with the ongoing management of chronic conditions, medication monitoring, navigating the health system and community services, and other forms of assistance (Table 2). These activities are consistent with those required by CPC. 

Several care managers helped patients and caregivers navigate the healthcare system and community-based resources when they needed medical equipment, home health care, or affordable medications. As one patient noted, “[The care manager] was a go-between with the [staff at the Agency] on Aging, who were case managing my home modification, and between some of the providers, and then also [for] anything that we needed from [my primary care physician], like a prescription for grab bars or a wheelchair.”

Care managers also helped patients and caregivers prepare for being discharged from hospitals and EDs. A spouse caregiver noted, “[The care manager] helped us go through some of the parameters of what would be a good [rehabilitation program] for him. Then she just kept in touch with us about things that we might need [and] resources in the that [my husband] could come home rather than have to go to a nursing home indefinitely.” 

Patients in most practices reported that their care manager played less of a role in coordinating with specialists. In general, clerical staff in the practices helped patients make appointments with specialists and tracked down the specialists’ notes; physicians then explained the specialists’ recommendations to patients.

Patient Satisfaction With Care Managers

Over half of patients reported having regular contact with their care manager and were willing to work with their care manager to manage their health conditions; such patients felt that the care manager was an asset to their team. In addition, there were patients who needed less frequent contact, but still valued help from care managers.

Many patients valued their care manager’s help in managing and monitoring their chronic conditions. As one patient reported, “[My care manager] calls on a regular basis to check in on me and see...if I need anything or basically how I’m feeling and if I think [my physical therapy] is helping me.” Some of these patients noted that their care manager offered them practical advice on how to meet their health goals. One said, “They know that it’s hard for me to exercise—but they still encourage me to do what I can. [My care manager] told me to take 2 cans of soup and put ’em on the top of my feet and just raise ’em up…, but that’s a suggestion that I wouldn’t have thought of.” They appreciated that their care manager took the time to help them understand how to implement their physicians’ recommendations and how to stay well after a hospitalization. 

Patients were also pleased with their care manager’s assistance with managing medications. One patient said that his care manager was particularly valuable when his medications were adjusted: “When we add one [medication], or we change one, it changes everything else. Because I take so many, it’s a complicated thing.”


Patients who reported having regular contact with their care manager or who were open to working with their care manager felt that the care manager was an asset to their team. Patients particularly valued care managers who listened to them and explained things in lay terms, helped to manage medications and chronic conditions, followed up after a hospitalization, and helped to navigate the healthcare delivery system and community resources. 

Although we purposely selected patients who were, according to their primary care practices, receiving care management services, one-fifth of patients (or their caregivers) could not identify a person at the practice other than the physician whom they felt fit the role of a care manager as we described it to them. This may reflect several factors, including inadequate integration of nurse care managers into primary care teams, lack of patient interest in engaging with a care manager, and repeated interactions with many individuals, such as home health aides and care managers from insurers and hospitals. We found variation among deep-dive practice clinicians’ efforts to introduce care managers to patients in person.8 Others have noted challenges to integration of care managers into the practice team, including a lack of experience with and knowledge of the best ways to design and implement effective care management; the limited availability of high-quality, standardized training for care managers; and a need to train practices to collaborate effectively with care managers.20 Other patients preferred not to interact with a care manager. 

It is likely that most patients barely recognized the term “care plan” because practices did not develop the plans systematically. Based on our site visits to the deep-dive practices,8 there is variation in the extent to which care plans are developed, used by care team members in a practice, and shared with patients. 

Given that we interviewed selected patients in selected practices in 1 initiative, our findings cannot be generalized to all CPC practices or all patients receiving care management. In addition, CPC practices received funding and learning support for care management, and other practices—particularly small, independent, or rural ones—may not have the financial resources or enough local nurses to hire even part-time care managers.21 

Nonetheless, the patient and caregiver feedback identifies ways primary care practices can improve care management: 1) Enhance the initial connection between patients and care managers by having physicians introduce care managers to patients in person and describing the benefits of care management; 2) Consider testing whether risk-stratification could also identify patients who might be amenable to changing health behaviors. Some patients who reported having limited contact with their care manager did not feel that they needed care management. Refining risk-stratification to identify patients willing to engage with care managers could focus care management resources on patients who need and are willing to use the services; 3) Train care managers to engage patients. Care managers, particularly those who lack formal case management training, may need guidance on gaining buy-in from disinterested patients. Because a few patients reported that their care manager did not initiate regular communication but advised them to call with questions or concerns, a more proactive approach may be beneficial; 4) Provide clinicians with technical assistance on how to explain the care manager’s role and how to delegate aspects of care to care managers in a way that is congruent with each care manager’s training, experience, licensure, and skills; 5) Coordinate care management resources across providers and health plans. Given the confusion among patients who also received outreach from “care managers” from health plans and hospitals, better coordination across these entities is necessary22,23; 6) Improve the use and understanding of care plans among clinicians and patients. Practices may need to better engage willing patients in care plan development to make the plans more recognizable and useful to patients; and 7) Use consistent terminology for “care manager” and “care plan” and develop broader agreement on the elements of these plans. This might help to promote a common understanding among providers and patients about care management and solidify provider and patient buy-in. Standardized terminology might also enhance efforts to evaluate patients’ experience with care management.


Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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