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The American Journal of Managed Care November 2018
The American Journal of Managed Care November 2018
CLINICAL
David H. Smith, PhD, RPh; Jennifer L. Kuntz, PhD; Lynn L. DeBar, PhD, MPH; Jill Mesa; Xiuhai Yang, MS; Jennifer Schneider, MPH; Amanda Petrik, MS; Katherine Reese, PharmD; Lou Ann Thorsness, RPh; David Boardman, MD; and Eric S. Johnson, PhD
COMMENTARY
Anupam B. Jena, MD, PhD; Jacquelyn W. Chou, MPP, MPL; Lara Yoon, MPH; Wade M. Aubry, MD; Jan Berger, MD, MJ; Wayne Burton, MD; A. Mark Fendrick, MD; Donna M. Fick, RN, PhD; David Franklin, BA; Rebecca Killion, MA; Darius N. Lakdawalla, PhD; Peter J. Neumann, ScD; Kavita Patel, MD, MSHS; John Yee, MD, MPH; Brian Sakurada, PharmD; and Kristina Yu-Isenberg, PhD, MPH, RPh
From The Editorial Board
Glen D. Stettin, MD
LETTERS TO THE EDITORS
Daniel B. Wolfson, MHSA, Executive Vice President and COO, ABIM Foundation
METHODS
Kathryn E. McCollister, PhD; Jared A. Leff, MS; Xuan Yang, MPH, MHS; Joshua D. Lee, MD; Edward V. Nunes, MD; Patricia Novo, MPA, MPH; John Rotrosen, MD; Bruce R. Schackman, PhD; and Sean M. Murphy, PhD
TRENDS FROM THE FIELD
Guneet K. Jasuja, PhD; Omid Ameli, MD, MPH; Donald R. Miller, ScD; Thomas Land, PhD; Dana Bernson, MPH; Adam J. Rose, MD, MSc; Dan R. Berlowitz, MD, MPH; and David A. Smelson, PsyD
WEB EXCLUSIVE
Currently Reading
Effects of a Community-Based Care Management Model for Super-Utilizers
Purvi Sevak, PhD; Cara N. Stepanczuk, MPP; Katharine W.V. Bradley, PhD; Tim Day, MSPH; Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Keith Kranker, PhD; Kate Stewart, PhD; and Lorenzo Moreno, PhD
Kelly Gao; Gene Pellerin, MD; and Laurence Kaminsky, PhD
Jennifer Elston Lafata, PhD; Carrie A. Miller, PhD, MPH; Deirdre A. Shires, PhD; Karen Dyer, PhD; Scott M. Ratliff, MS; and Michelle Schreiber, MD
Patricia R. Salber, MD, MBA; Christobel E. Selecky, MA; Dirk Soenksen, MS, MBA; and Thomas Wilson, PhD, DrPH
Jinyoung Shin, MD, PhD; Hyeonyoung Ko, MD, MPH; Jeong Ah Kim, BS; Yun-Mi Song, MD, PhD; Jin Seok Ahn, MD, PhD; Seok Jin Nam, MD, PhD; and Jungkwon Lee, MD, PhD
Effects of a Community-Based Care Management Model for Super-Utilizers
Purvi Sevak, PhD; Cara N. Stepanczuk, MPP; Katharine W.V. Bradley, PhD; Tim Day, MSPH; Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Keith Kranker, PhD; Kate Stewart, PhD; and Lorenzo Moreno, PhD
A community-based care management program for high-risk patients reduced hospital readmissions and also likely reduced admissions and Medicare parts A and B spending.
ABSTRACT
Objectives: Medicare, Medicaid, and commercial plans have all explored ways to improve outcomes for patients with high costs and complex medical and social needs. The purpose of this study was to test the effectiveness of a high-intensity care management program that the Rutgers University Center for State Health Policy (CSHP) implemented as an adaptation of a promising model developed by the Camden Coalition of Healthcare Providers.
Study Design: We estimated the impact of the program on 6 utilization and spending outcomes for a subgroup of beneficiaries enrolled in Medicare fee-for-service (n = 149) and a matched comparison group (n = 1130).
Methods: We used Medicare claims for all analyses. We used propensity score matching to construct a comparison group of beneficiaries with baseline characteristics similar to those of program participants. We employed regression models to test the relationship between program enrollment and outcomes over a 12-month period while controlling for baseline characteristics.
Results: A test of joint significance across all outcomes showed that the CSHP program reduced service use and spending in aggregate (P = .012), although estimates for most of the individual measures were not statistically significant. Participants had 37% fewer unplanned readmissions (P = .086) than did comparison beneficiaries. Although we did not find statistically significant results for the other 5 outcomes, the CIs for these outcomes spanned substantively large effects.
Conclusions: Although these findings are mixed, they suggest that adaptations of the Camden model hold promise for reducing short-term service use and spending for Medicare super-utilizers.
Am J Manag Care. 2018;24(11):e365-e370Takeaway Points
An independent evaluation of a high-intensity care management program implemented by provider groups in 4 states shows that the model holds promise for efforts to reduce short-term service use and spending based on an analysis of 149 Medicare patients with complex medical and social needs. These findings may help managed care decision-makers to:
So far, interest in programs to help super-utilizers has outpaced the available evidence on their effectiveness. Results from an early evaluation of the Camden model were promising: The Camden Coalition reported reductions in emergency department (ED) visits, inpatient admissions, and average charges per month among participants in a pilot program.7,8 However, the study included only 36 participants and used a pre-post design that did not control for regression to the mean or for confounding factors that might influence outcomes. Regression to the mean is particularly important in interventions in which patients are selected because of their recent service use; some decline in service use post enrollment would be expected without any intervention.9 No independent rigorous evaluation of the Camden model has been published to date, although a randomized controlled trial is ongoing.1 Evaluations of similar care management models have yielded mixed findings over time.3,4,10-13
Recognizing the need for evidence, the Center for Medicare & Medicaid Innovation awarded a $14.3-million Health Care Innovation Award to the Rutgers University Center for State Health Policy (CSHP) to support adoption of the Camden model by provider groups in 4 states: (1) an independent physician association in San Diego, California; (2) a nonprofit community health center in Aurora, Colorado; (3) a nonprofit health system with 2 hospitals in Kansas City, Missouri; and (4) a nonprofit operator of 2 federally qualified health centers in Allentown, Pennsylvania. These provider groups targeted super-utilizers living in poor neighborhoods within their service areas.
Researchers affiliated with the Aurora site provided suggestive evidence on the program’s impacts on a group of primarily Medicaid-eligible beneficiaries. They found that it reduced ED visits and hospitalizations and increased primary care use among program participants in Colorado.14 However, the study’s comparison group included patients who declined to participate in the program, potentially biasing results.
In this article, we present evidence from an independent evaluation of the CSHP program across all 4 sites. Our evaluation included prespecified hypotheses that the program would (1) reduce total admissions, particularly readmissions, and (2) reduce Medicare parts A and B spending.15 We used rigorous tests that account for regression to the mean with a well-matched comparison group. This study provides a unique perspective on how the original Camden model can be adapted to a variety of settings and provider groups and adds to the available evidence on care management programs for super-utilizers.
METHODS
Enrollment
The 4 CSHP sites enrolled 1068 participants between January 2013 and June 2015. Initially, all 4 sites used the same utilization-based criteria as the Camden model—2 or more hospital admissions in the past 6 months—to identify potential participants. Two sites amended these thresholds early in the award period to expand the pool of potential participants: One site targeted individuals with 2 or more hospital admissions in the prior 6 months or 3 or more admissions in the prior 12 months, and the other targeted individuals with 3 or more hospital events (admissions or ED visits) in the prior 6 months. Among those who met the utilization-based criteria, the sites excluded patients whose conditions, such as cancer or serious behavioral issues, could not be managed with existing program resources.16
Intervention
All 4 sites received technical assistance from the Camden Coalition to guide implementation of the intervention. The sites implemented the same basic set of activities, including development of individualized care plans, integrated care management services through mobile care teams, and education to improve patients’ ability to manage their medical and social needs. Care teams, which included some combination of nurses, community health workers, social workers, medical assistants, and/or behavioral health providers, provided education about the importance of using primary and specialty care instead of, or as a follow-up to, emergency and hospital care. They also addressed participants’ nonmedical needs, including enrollment in social services (such as housing and Social Security disability benefits) and behavioral health service programs.
On average, teams contacted participants 10 times per month, spending roughly 6 hours with each participant per month. The majority of that time (87%) was spent in person, at the participants’ homes and medical appointments, and the remainder was on the phone. Participants remained in the program for an average of 4.2 months, ideally until their health and social circumstances had stabilized and the program could graduate them. By June 2015, the program had graduated 673 participants, although some continued to receive occasional support from the care teams. Additional detail on the intervention is available in a CMS evaluation report.16
Objectives: Medicare, Medicaid, and commercial plans have all explored ways to improve outcomes for patients with high costs and complex medical and social needs. The purpose of this study was to test the effectiveness of a high-intensity care management program that the Rutgers University Center for State Health Policy (CSHP) implemented as an adaptation of a promising model developed by the Camden Coalition of Healthcare Providers.
Study Design: We estimated the impact of the program on 6 utilization and spending outcomes for a subgroup of beneficiaries enrolled in Medicare fee-for-service (n = 149) and a matched comparison group (n = 1130).
Methods: We used Medicare claims for all analyses. We used propensity score matching to construct a comparison group of beneficiaries with baseline characteristics similar to those of program participants. We employed regression models to test the relationship between program enrollment and outcomes over a 12-month period while controlling for baseline characteristics.
Results: A test of joint significance across all outcomes showed that the CSHP program reduced service use and spending in aggregate (P = .012), although estimates for most of the individual measures were not statistically significant. Participants had 37% fewer unplanned readmissions (P = .086) than did comparison beneficiaries. Although we did not find statistically significant results for the other 5 outcomes, the CIs for these outcomes spanned substantively large effects.
Conclusions: Although these findings are mixed, they suggest that adaptations of the Camden model hold promise for reducing short-term service use and spending for Medicare super-utilizers.
Am J Manag Care. 2018;24(11):e365-e370Takeaway Points
An independent evaluation of a high-intensity care management program implemented by provider groups in 4 states shows that the model holds promise for efforts to reduce short-term service use and spending based on an analysis of 149 Medicare patients with complex medical and social needs. These findings may help managed care decision-makers to:
- Reduce spending among super-utilizers through the use of mobile interdisciplinary care teams
- Address social determinants of health that contribute to high spending
- Adapt community-based care management models to suit local contexts
So far, interest in programs to help super-utilizers has outpaced the available evidence on their effectiveness. Results from an early evaluation of the Camden model were promising: The Camden Coalition reported reductions in emergency department (ED) visits, inpatient admissions, and average charges per month among participants in a pilot program.7,8 However, the study included only 36 participants and used a pre-post design that did not control for regression to the mean or for confounding factors that might influence outcomes. Regression to the mean is particularly important in interventions in which patients are selected because of their recent service use; some decline in service use post enrollment would be expected without any intervention.9 No independent rigorous evaluation of the Camden model has been published to date, although a randomized controlled trial is ongoing.1 Evaluations of similar care management models have yielded mixed findings over time.3,4,10-13
Recognizing the need for evidence, the Center for Medicare & Medicaid Innovation awarded a $14.3-million Health Care Innovation Award to the Rutgers University Center for State Health Policy (CSHP) to support adoption of the Camden model by provider groups in 4 states: (1) an independent physician association in San Diego, California; (2) a nonprofit community health center in Aurora, Colorado; (3) a nonprofit health system with 2 hospitals in Kansas City, Missouri; and (4) a nonprofit operator of 2 federally qualified health centers in Allentown, Pennsylvania. These provider groups targeted super-utilizers living in poor neighborhoods within their service areas.
Researchers affiliated with the Aurora site provided suggestive evidence on the program’s impacts on a group of primarily Medicaid-eligible beneficiaries. They found that it reduced ED visits and hospitalizations and increased primary care use among program participants in Colorado.14 However, the study’s comparison group included patients who declined to participate in the program, potentially biasing results.
In this article, we present evidence from an independent evaluation of the CSHP program across all 4 sites. Our evaluation included prespecified hypotheses that the program would (1) reduce total admissions, particularly readmissions, and (2) reduce Medicare parts A and B spending.15 We used rigorous tests that account for regression to the mean with a well-matched comparison group. This study provides a unique perspective on how the original Camden model can be adapted to a variety of settings and provider groups and adds to the available evidence on care management programs for super-utilizers.
METHODS
Enrollment
The 4 CSHP sites enrolled 1068 participants between January 2013 and June 2015. Initially, all 4 sites used the same utilization-based criteria as the Camden model—2 or more hospital admissions in the past 6 months—to identify potential participants. Two sites amended these thresholds early in the award period to expand the pool of potential participants: One site targeted individuals with 2 or more hospital admissions in the prior 6 months or 3 or more admissions in the prior 12 months, and the other targeted individuals with 3 or more hospital events (admissions or ED visits) in the prior 6 months. Among those who met the utilization-based criteria, the sites excluded patients whose conditions, such as cancer or serious behavioral issues, could not be managed with existing program resources.16
Intervention
All 4 sites received technical assistance from the Camden Coalition to guide implementation of the intervention. The sites implemented the same basic set of activities, including development of individualized care plans, integrated care management services through mobile care teams, and education to improve patients’ ability to manage their medical and social needs. Care teams, which included some combination of nurses, community health workers, social workers, medical assistants, and/or behavioral health providers, provided education about the importance of using primary and specialty care instead of, or as a follow-up to, emergency and hospital care. They also addressed participants’ nonmedical needs, including enrollment in social services (such as housing and Social Security disability benefits) and behavioral health service programs.
On average, teams contacted participants 10 times per month, spending roughly 6 hours with each participant per month. The majority of that time (87%) was spent in person, at the participants’ homes and medical appointments, and the remainder was on the phone. Participants remained in the program for an average of 4.2 months, ideally until their health and social circumstances had stabilized and the program could graduate them. By June 2015, the program had graduated 673 participants, although some continued to receive occasional support from the care teams. Additional detail on the intervention is available in a CMS evaluation report.16
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