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The American Journal of Managed Care December 2019
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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.
Description of the Intervention

CMs and CHWs received staff training conducted by Johns Hopkins HealthCare (JHHC). For J-CHiP, CHWs initiated contact with eligible patients by telephone or in person to complete an initial “barriers to care” assessment, with appropriate outreach and follow-up. In-person contacts took place in patients’ homes or primary care clinics. The CHWs’ primary responsibility was to identify and intervene on identified barriers to care, such as difficulty accessing healthy food, unstable housing, lack of transportation, and insufficient financial resources. CHWs arranged for transportation, assisted with resource insufficiency, improved communication, and ensured treatment comprehension. They also reinforced health education, provided social support, and provided reminders.

After the CHW assessment, a CM contacted enrolled patients via telephone or in person. The CM role followed National Committee for Quality Assurance (NCQA) Health Plan Accreditation Standards for Complex Case Management. CMs performed a baseline assessment to identify healthcare needs, followed by care coordination, monitoring, and evaluation of services. They also assessed the patient’s level of health engagement and assisted patients by setting goals, acting as a patient liaison to coordinate care needs, and communicating with the care team to develop a plan to reflect the desired outcome. Due to the all-condition model, CMs did not utilize structured, disease-tailored interventions targeting clinical outcomes. A goal for CMs was to follow up with patients at least once every 3 months per JHHC health plan policy.

CM and CHW staff used an electronic care management documentation system to document patient information and program workflows. Reports of process metrics were reviewed monthly.

Data Sources and Measures

Data for analyses were obtained from the electronic care management documentation system, electronic health record, and insurance claims. CMs and CHWs documented every encounter with patients, including successful and unsuccessful attempts via telephone or in person. For each enrolled patient, the number of successful contacts made by CMs and CHWs was calculated.

Four distinct intervention intensity categories were created based on the distribution of successful CM and CHW contacts and national guidelines. For CM, low intensity was defined as less than 1 successful contact every 3 months based on NCQA and program goals. High intensity was defined as 1 or more successful contacts per 3 months. Due to a lack of standardized national guidelines for recommended CHW contact frequency, low intensity of CHW contacts was defined as below the 75th percentile in average number of contacts per month enrolled in the program. High CHW contact intensity was defined as above the 75th percentile. Thus, the 4 mutually exclusive categories of program intensity were (1) low CM–low CHW (reference group), (2) low CM–high CHW, (3) high CM–low CHW, and (4) high CM–high CHW (eAppendix Table 1 [eAppendix available at]).

Primary outcomes for analyses were the rates of ED visits, hospitalizations, and 30-day hospital readmissions, all obtained from insurance claims data. To obtain a baseline for each patient, utilization rates prior to J-CHiP were obtained for the 12 months prior to program enrollment. Baseline utilization rates are presented per month during that 12-month period. Postprogram utilization rates were analyzed for the 12 months or more following each patient’s enrollment in the care management program, through December 31, 2015, the end of J-CHiP. Healthcare utilization rates were monitored while patients were enrolled in the program and are presented per months enrolled in the program.

Statistical Analyses

Baseline characteristics were stratified by health insurance. Mann-Whitney U and χ2 tests were used to detect differences among continuous and categorical variables, respectively. Barriers to care and risk of hospitalization, via ACG score, were stratified by program intensity and health insurance.

Negative binomial regression models were used to evaluate the risk ratio of ED visits and hospitalizations for each program intensity with the low CM–low CHW category as reference group. A zero-inflated negative binomial model was used to model the risk ratio of readmissions to account for the excessive number of patients with zero readmissions (eAppendix Figures 1-6). Because longitudinal data were available at the patient level, a Poisson regression model using generalized estimating equations (GEE) was used to account for within-patient correlations. This approach allows determination of whether program intensity is associated with a difference in each primary outcome and is in contrast to time-series analyses, which are used when only group-level, aggregated data are available.16 In sensitivity analyses, models were run using a 50th percentile cutoff for CHW contacts and a 90th percentile threshold for CM contacts compared with the NCQA standard. Additional models with baseline rate of healthcare utilization preintervention, clinic site, and comorbidities were also run. All models looked at CM contacts per 3 months, were stratified by Medicaid and Medicare, and adjusted for age at enrollment, sex, ACG score, race, and baseline rate of the primary outcome prior to implementation of J-CHiP. In pre–post analyses, we evaluated the percent change in adjusted healthcare utilization for each primary outcome by modeling the monthly rates during the 12-month period before and in the period after care management program enrollment using GEE with a Poisson distribution.

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