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The American Journal of Managed Care December 2019
Clinical Characteristics and Treatment Patterns Among US Patients With HIV
Julie L. Priest, MSPH; Tanya Burton, PhD; Cori Blauer-Peterson, MPH; Kate Andrade, MPH; and Alan Oglesby, MPH
Partnering in Postacute Darkness? CMS Has Data That Will Help
Terry E. Hill, MD
From the Editorial Board: Anne K. Gauthier, MS
Anne K. Gauthier, MS
Preventive/Office Visit Patient Knowledge and Their Insurance Information Gathering Perceptions
Evan K. Perrault, PhD; Katie J. Schmitz, BA; Grace M. Hildenbrand, MA; and Seth P. McCullock, MA
Cost-Sharing Payments for Out-of-Network Care in Commercially Insured Adults
Wendy Yi Xu, PhD; Bryan E. Dowd, PhD; Macarius M. Donneyong, PhD; Yiting Li, PhD; and Sheldon M. Retchin, MD, MSPH
Benzodiazepine and Unhealthy Alcohol Use Among Adult Outpatients
Matthew E. Hirschtritt, MD, MPH; Vanessa A. Palzes, MPH; Andrea H. Kline-Simon, MS; Kurt Kroenke, MD; Cynthia I. Campbell, PhD, MPH; and Stacy A. Sterling, DrPH, MSW
Catheter Management After Benign Transurethral Prostate Surgery: RAND/UCLA Appropriateness Criteria
Ted A. Skolarus, MD, MPH; Casey A. Dauw, MD; Karen E. Fowler, MPH; Jason D. Mann, MSA; Steven J. Bernstein, MD, MPH; and Jennifer Meddings, MD, MS
A Claims-Based Algorithm to Reduce Relapse and Cost in Schizophrenia
Heidi C. Waters, PhD, MBA; Charles Ruetsch, PhD; and Joseph Tkacz, MS
Cost Burden of Hepatitis C Virus Treatment in Commercially Insured Patients
Christine Y. Lu, PhD; Dennis Ross-Degnan, ScD; Fang Zhang, PhD; Robert LeCates, MA; Caitlin Lupton, MSc; Michael Sherman, MD; and Anita Wagner, PharmD
Delivery System Performance as Financial Risk Varies
Joseph P. Newhouse, PhD; Mary Price, MA; John Hsu, MD, MBA; Bruce Landon, MD, MBA; and J. Michael McWilliams, MD, PhD
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Association of Care Management Intensity With Healthcare Utilization in an All-Condition Care Management Program
Hussain S. Lalani, MD; Patti L. Ephraim, MPH; Arielle Apfel, MPH; Hsin-Chieh Yeh, PhD; Nowella Durkin; Lindsay Andon, MSPH; Linda Dunbar, PhD; Lawrence J. Appel, MD; and Felicia Hill-Briggs, PhD; for the Johns Hopkins Community Health Partnership

Association of Care Management Intensity With Healthcare Utilization in an All-Condition Care Management Program

Hussain S. Lalani, MD; Patti L. Ephraim, MPH; Arielle Apfel, MPH; Hsin-Chieh Yeh, PhD; Nowella Durkin; Lindsay Andon, MSPH; Linda Dunbar, PhD; Lawrence J. Appel, MD; and Felicia Hill-Briggs, PhD; for the Johns Hopkins Community Health Partnership
Higher intensity of care management in an all-condition program addressing care coordination and care barriers was associated with increased healthcare utilization among Medicaid and Medicare patients.
ABSTRACT

Objectives: To identify care needs among Medicaid and Medicare patients in an all-condition care management program involving case managers (CMs) and community health workers (CHWs), and to examine the relationship between intervention intensity and healthcare utilization.

Study Design: Retrospective longitudinal evaluation of managed care–hired CMs and CHWs based at 8 primary care sites participating in the Johns Hopkins Community Health Partnership (J-CHiP).

Methods: Patients at high risk for hospitalization were enrolled in J-CHiP. CMs provided care coordination and CHWs addressed barriers to care. Four program intensity categories were created: low CM–low CHW, low CM–high CHW, high CM–low CHW, and high CM–high CHW. We evaluated the adjusted relative risk (RR) of emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions pre– and post enrollment in the program using CM documentation, electronic health record data, and insurance claims.

Results: Among 1408 Medicaid and 2196 Medicare patients, the predominant barriers to care were lack of transportation, unstable housing, medication payment, and healthy food access. Among Medicaid and Medicare patients, high CM–high CHW and high CM–low CHW intensities were associated with a higher adjusted risk of hospitalization and 30-day hospital readmission after program implementation compared with low CM–low CHW intensity. Among patients with low CM–high CHW intensity, Medicaid patients had a higher risk of readmission (RR, 1.47; P = .016) and Medicare patients had a higher risk of ED visit (RR, 1.33; P = .001) post program implementation.

Conclusions: In this longitudinal evaluation of an all-condition, unstructured, managed care organization–led program, preprogram trajectories of healthcare utilization rates among patients increased rather than decreased after program implementation, especially among patients receiving the highest care management program intensity.

Am J Manag Care. 2019;25(12):e395-e402
Takeaway Points

Higher intensity of care management in an all-condition, combined case manager (CM) and community health worker (CHW) program among high-risk Medicaid and Medicare patients was associated with increased, rather than decreased, emergency department (ED) visits, hospitalizations, and hospital readmissions.
  • Observed preprogram patterns in utilization rates continued post program, irrespective of program intensity.
  • Findings differ from those of structured, disease-specific programs using CMs and CHWs, which show decreased utilization with higher program intensity.
  • Questions raised for future programs include the effectiveness of an all-condition versus disease-specific approach and the potential role for evidence-based CM and CHW interventions for appropriate clinical goals and barriers to care outcomes.
A commonly used approach to achieve the Triple Aim of improving the experience of care, improving the health of populations, and reducing per capita costs of healthcare1 is to identify high-risk patients—often those with multiple chronic conditions (eg, heart disease, cancer, stroke, diabetes)—for team-based case management.2 Case management programs have become routine within healthcare to coordinate care and address the social and behavioral needs of high-risk patients. The majority of state Medicaid programs now mandate comprehensive managed care programs that include a case management component.3

Similarly, adoption of community health worker (CHW) programs has increased. Systematic reviews report mixed effectiveness on outcomes but suggest that certain CHW programs can improve health outcomes, increase appropriate healthcare service use,4 as well as reduce emergency department (ED) visits and hospitalizations, and achieve cost savings.5 A key priority of the CMS Equity Plan is to increase the ability of the healthcare workforce, including CHWs, to meet the needs of vulnerable populations.6 These programs are also consistent with the CDC’s recommendation for an integrated and sustainable CHW workforce in public health to prevent and manage chronic diseases.7

Within Medicaid populations, some case management or case manager (CM) programs have been effective at reducing outpatient healthcare utilization, including ED visits and hospitalizations.8-11 Evaluations of certain programs have also documented that greater intensity of intervention was associated with reduced healthcare utilization.8,12 These programs focused on a single condition, such as diabetes, and generally delivered evidence-based, condition-specific interventions.12,13

Few studies have evaluated all-condition, combined CM and CHW programs in routine care among adult Medicaid and Medicare beneficiaries. The present analyses were conducted in the setting of the Johns Hopkins Community Health Partnership (J-CHiP), a Center for Medicare and Medicaid Innovation (CMMI) Healthcare Innovation Awardee. The objectives of this study were to identify care needs among high-risk Medicaid and Medicare patients in the J-CHiP primary care–based care management program involving CMs and CHWs, and to examine whether program intensity was associated with changes in healthcare utilization from baseline. We hypothesized that as program intensity increased, healthcare utilization would decrease.

METHODS

Study Setting

J-CHiP began in July 2012 as a CMMI Healthcare Innovation Awardee. The initiative was specifically designed to target patients with chronic conditions requiring high utilization of health services. The goal was to achieve the Triple Aim.14 J-CHiP concurrently implemented 3 care delivery models, each addressing different settings of care: an acute care model, a skilled nursing facilities model, and a community care delivery model.14 The community care delivery model consisted of 3 delivery programs: care management and 2 programs implemented by community-based nonprofit organizations. This analysis focuses on the care management program, which was delivered at 8 community-based primary care clinical practice sites in Baltimore City, Maryland. At each site, clinic-embedded CMs and CHWs were part of multidisciplinary ambulatory care teams led by primary care physicians.

The Johns Hopkins School of Medicine Institutional Review Board approved this J-CHiP analysis.

Patient Population

Patients were enrolled in the care management program from December 2012 through June 2015. Eligible patients were aged at least 18 years, were enrolled in Priority Partners Managed Care Organization or Medicare, had at least 1 chronic condition, were not pregnant, and received care at 1 of 8 participating primary care clinics. Patients were primarily identified for care management program enrollment using the Johns Hopkins Adjusted Clinical Groups (ACG) System predictive model to assess risk of hospitalization in the next year. This ACG risk stratification was based on clinical and utilization data, including age, comorbidities, and inpatient and outpatient healthcare utilization over the previous 12 months.15 ACG scores range from 0 to 1.00, with higher scores indicating greater risk of hospitalization. No specific cutoff identified eligible patients; highest-risk patients were prioritized. A second method of patient identification was healthcare provider referral. Patients with end-stage renal disease (ESRD) were ineligible, as they were referred to an existing ESRD-specific care management program.

For this analysis, patients were considered enrolled in the program once a CHW made successful contact with the patient to initiate care management program services.


 
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