Primary Care Managers Supported by Information Technology Systems Improve Outcomes, Reduce Costs For Patients With Complex Conditions

Problem Addressed

• Many elders with multiple, costly chronic conditions: Sixty-five percent of the Medicare-funded population have two or more chronic conditions and represent 95 percent of Medicare costs. Patients with chronic illness account for 75 percent of health care expenditures in the United States.
• Failure of current model to serve these individuals: There are many problems with the current primary care model for elderly individuals, as outlined below:
  • Inadequate care management: Most elderly patients receive medical care in independent, primary care provider clinics, where there are no intervention or care management services available. As a result, patients receive inadequate care. For example, one-half of patients with various chronic diseases, including diabetes, hypertension, congestive heart failure, and depression, are managed inadequately.¹
  • Lack of ability to implement best practices: Although physicians may know guidelines, systematically implementing best practices is both time-consuming and difficult. In addition, primary care physicians often lack the time or resources to coordinate care with the specialists, tap appropriate community services, and contact others who need to be involved in the care of a patient.²
  • Lack of incentives: Under the current payment structure, primary care physicians have no financial incentive to provide coordinated care management to elderly individuals, as the benefits of such activities (e.g., fewer hospitalizations) benefit the payer rather than the provider.³
  • Lack of team structure: Health care teams composed of patients, nurses, physicians, social workers, therapists, and others, are important for successful care management. However, often these teams do not exist in primary care settings, and, if they do, they may not function well.^4,5
  • Lack of information technology (IT): Primary care clinics often lack the IT needed to provide comprehensive patient information and support effective communication between all members of a health care team, including the patient and his or her caregiver. Even when IT systems are implemented, many key functions needed to ensure high-quality, patient-centered care are not available.
• Leading to avoidable hospitalizations, complications, and deaths: Medicare patients with multiple chronic illnesses are 98 times more likely to be hospitalized than are patients with no chronic illnesses; many of these hospitalizations could be prevented with better care management and coordination in the primary care setting.⁶

Description of the Innovative Activity

• Initial referral: Physicians are trained and encouraged to refer patients, with one or more chronic conditions, to a care manager embedded in their practices for any perceived care management need, including one or more chronic conditions, especially in the elderly, or for a social need. Other clinical staff may also refer patients to care managers. The referral system is intentionally flexible, so patients with a broad spectrum of issues can be referred, which distinguishes it from a disease management program. About 3 to 5 percent of patients at an all-ages primary care practice, or 10 percent (or more) of a practice geared toward older adults may be referred. During the first year of the program, care management services were pilot tested in seven clinics, with services provided to 1.7 percent of the 106,766 adult patients seen. At present, more than 70 clinics have implemented the program.
• Development of individualized care plan: The care manager, who may be a nurse or social worker, meets with the patient, assesses his or her needs, and formulates an individual plan with the patient and his/her caregivers. The manager’s goal is to enact a high-quality, cost-effective care plan by providing education and coaching (e.g., about self-management of chronic illnesses), and identifying and removing barriers. During the first year of the program, each care manager cared for an average of 292 patients.
• Periodic encounters with the patient: The care manager is in regular contact with the patient, as needed; the typical care manager had 4.3 encounters per patient per year, including face-to-face visits (which account for roughly one-third of encounters), telephone calls (roughly 40 percent of encounters), and joint meetings with a medical team member (roughly 16 percent). Many of the encounters focused on self-management support and motivation.
• Tapping into other resources and settings: As needed, the care manager can schedule home appointments with the patients, converse with physicians and specialists, contact outside agencies and companies to advocate for patients, or arrange other services to bolster the patient’s care and well-being. The care manager bridges the gaps in the fragmented health care system and formulates, interprets, and applies care plans. Roughly one-half (46.9 percent) of encounters involved providing patients or caregivers with connections to community programs. In many cases, care managers are helping patients and caregivers to deal with social and organizational needs, such as caregiver fatigue, medication assistance, and financial needs.

• Individual patient record: The patient’s record contains a standardized problem list, progress notes, a list of prescribed medications, drug interaction reminders, laboratory results, and radiology results. It also contains other tests, procedures, provider messages, and patient summaries.
• Longitudinal database: A longitudinal record is available to all clinicians, including care managers, in all clinics and provides information across time and from multiple settings, including hospitals, emergency rooms, specialty practices, and general outpatient practices.
• Reminders and alerts about needed care: The information system promotes adherence to best practices by issuing alerts, reminders, and suggestions based on automatic evaluation of rules. For example, the system will alert providers to the need for eye and foot exams and hemoglobin A1c testing for patients with diabetes. The care team utilized the computer system to access best-practice guidelines in nearly one-half of their activities. Appropriate standards-based alerts were issued and seen by physicians for 28 percent of patients with diabetes. Care manager alerts, or “tickler” lists, were triggered during 63 percent of working days.
• Performance reports: The program generates report cards that evaluate the degree to which each physician attains his or her clinical goals with patients, including adherence to best practices and proper patient monitoring.
• Communication between physician and care manager: The system also provides a mechanism for physicians and care managers to communicate with each other on issues relevant to the patient’s care. Analysis shows that care managers and physicians frequently use this feature, with care managers sending or receiving messages on 73.7 percent of their patients and physicians doing the same for 38.7 percent of their patients.

References/Related Articles

Dorr DA, Wilcox A, Burns L, et al. Implementing a multidisease chronic care model in primary care using people and technology. Dis Manag. 2006 Feb; 9(1):1-15. [PubMed] Available at: http://www.caremanagementplus.org/documents/Dorr_DM.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software.).

Dorr D, Bonner LM, Cohen AN, et al. Informatics systems to promote improved care for chronic illness: a literature review. J Am Med Inform Assoc. 2007 March-April;14(2):156-163. [PubMed]

Donnelly S, Burns L. Using clinic-based care managers to improve quality outcomes and increase efficiency in primary care. Quality Insight. Fall 2006:7-8. Available at: http://www.healthinsight.org/archives/assets/quality_insight/QualityInsight%20Fall%202006%20web.pdf.

Dorr DA, Jones SS, Burns L, et al. Use of health-related, quality-of-life metrics to predict mortality and hospitalizations in community-dwelling seniors. J Am Geriatr Soc. 2006 Apr;54(4):667-73. [PubMed]

Dorr DA, Wilcox A, McConnell KJ, et al. Productivity enhancement for primary care providers using multicondition care management. Am J Manag Care. 2007 Jan;13(1):22-8. [PubMed]

Dorr DA, Wilcox A, Jones SS, et al. Care management dosage. J Gen Intern Med. 2007 Jun;22(6):736-41. [PubMed]

Wilcox AB, Jones SS, Dorr DA, et al. Use and impact of a computer-generated patient summary worksheet for primary care. AMIA Annu Symp Proc. 2005:824-8. [PubMed]

Dorr DA, Wilcox A, Donnelly SM, et al. Impact of generalist care managers on patients with diabetes. Health Serv Res. 2005 Oct;40(5 Pt 1):1400-21. [PubMed]

Dorr DA, Wilcox AB, Brunker CP, et al. The effect of technology supported, multidisease care management on the mortality and hospitalization of seniors. J Am Geriatr Soc. 2008 Dec;56(12):2195-2202. [PubMed]

Contact the Innovator

Results

• Enhanced access to services: Care-managed patients averaged 6.5 visits per year at the clinics, compared with 2.6 visits for the rest of the clinic population. Patients with diabetes (representing 37 percent of visits) and mental health issues (33 percent) were treated most commonly.
• Improved outcomes: Seniors with diabetes who were enrolled in the program had better control of their blood sugars and were more likely to be regularly tested. Care-managed patients with diabetes had three-fold greater reductions in glucose levels (hemoglobin A1c levels) compared to the control group. They also had 15 to 25 percent fewer long-term complications, 20 percent lower mortality, and 24 percent fewer hospitalizations compared to a control group.
• Reduced costs: The costs of intervention in patients with depression decreased by 8 percent, while the costs for patients in a control group increased 19 percent. The program resulted in an average reduction in medical costs of roughly $200,000 per clinic due to the avoidance of unnecessary services at the primary care level. It is estimated that if 2 percent of the nation’s primary care providers adopted care coordination programs like Care Management Plus, Medicare could potentially save over $100 million each year.⁷
• Enhanced productivity: Productivity, measured by adjusted relative value units, was 8 to 12 percent higher among the 50 physicians who used the program, compared with 72 control physicians. The increased physician productivity generated an additional $99,000 per clinic, which roughly covered the cost of the care manager and training.
• Net benefits to society: The program yielded estimated benefits of about $175,000 to society in avoided medical costs and increased physician efficiency, or a net benefit of about $75,000 after program costs.⁸ Much of the benefit of decreased demand for services accrued to payers and patients in the form of reduced utilization of services and better health. This effect was mainly seen in patients with complex chronic illness, including diabetes, and varied depending upon patient population. Continuing studies are examining the net effect on costs in different settings.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Developing job descriptions: The job description for the care manager is derived from the Case Management Society of America's definition of case management, but it is flexible so that each clinic can modify the description to suit its needs. Most care managers are nurses, but they can be licensed practical nurses or social workers.
• Training: Each care manager undergoes a one-time curriculum that provides specialized training in educating, motivating, and coaching patients; disease-specific protocols; caring for seniors; and supporting their caregivers. Care managers support the same clinical guidelines as clinicians and attend the same interdisciplinary workshops. The training also addresses how to assess resources in the community such as respite and tax breaks for caregivers, community meal provision, different housing options, and obtaining health and environment assessments at home. Training was initially a one-time session but has evolved into a combination of in-person and online (8-week) course work. Care managers are encouraged to collaborate with others in the Care Management Plus network to continue learning.
• Developing, refining IT support: Information systems supporting collaborative care for multiple diseases were developed and integrated to enable access to relevant patient information, encourage best practices, and facilitate communication between providers. These systems are continually revised to enhance connectivity and expand population management functionality. IT support and consultation may be provided during implementation depending on clinic needs and available internal IT staff/support.
• Program expansion: As noted, the program has been expanded to over 70 clinics. For each new clinic, a dissemination plan is developed that incorporates multiple facets of implementation, including financial and organizational considerations, referral specifications, information technology use and needs, and evaluation processes.

Resources Used and Skills Needed

• Staffing: Each of the seven care managers are paid roughly $75,000 a year.
• Costs: The training for each care manager costs roughly $25,000. The software systems were made available to all Intermountain Healthcare clinics free of charge.

Funding Sources

Intermountain Healthcare; Hartford Foundation

Tools and Other Resources

Getting Started with This Innovation

• Assess clinic size: Clinics need to have at least six physicians to support a care manager. The innovators are currently experimenting with a model of shared care managers across two or more clinics. 
• Reorganize around teams: Each clinic must be prepared to reorganize its staff to create a team-based approach toward patient care.
• Revamp IT systems (and do not underestimate IT needs): The ability to track and coordinate care requires an IT system that is rarely in place in primary care clinics. Even with an EHR, the specific needs of care managers—care plan creation, best practices reminders and tracking, and facilitation of communication with the entire team—are often not met by the system. As a result, most clinics must upgrade and/or acquire adequate IT systems for the program and devote the time and resources needed to train staff to use the system and implement its protocols. As noted, Care Management Plus is willing to make its software available to all clinics to integrate into their systems and to assist with training.
• Enlist practice leader support: This model requires significant time and training to implement, and there must be a strong commitment on the part of practice leaders to see it through to completion.

Sustaining This Innovation

• Work with payers to revise reimbursement: Developing the expertise in care coordination takes time, effort, and financial resources that are currently not adequately recognized by payment systems; payers may be willing to take into account the expertise required to successfully implement this program when revamping payment structures, particularly as the "medical home" model becomes more prominent. In the interim, smaller clinics that implement care coordination services may endure a net financial loss. 
• Monitor the number of physician alerts, and adjust accordingly: Although reminders can be useful when used appropriately, the complexity of individual patient needs can result in the issuing of many alerts, which may be viewed negatively by physicians.
• Ensure adequate time for care manager-patient communication: There can be significant variation in the goals of the patients and the roles of the care managers. Although there are protocols for the management of specific diseases, patients often have more holistic concerns about the quality of their lives and health than do care managers. The more time care managers spend in face-to-face meetings with patients to discuss services, education, motivations, and barriers to success, the better the health outcomes for patients.

Additional Considerations and Lessons

• Information systems: Information systems supporting collaborative care for multiple diseases need to provide three core functionalities: access to relevant patient information, encouragement of best practices, and facilitating communications between all health care providers. Through a grant from the John A. Hartford Foundation, the software developed for the Care Management Plus program is available free of charge to practices interested in adopting the model. 
• Care manager implementation support: Intermountain and Oregon Health & Science University is willing to train and support primary care clinics that are interested in adding a care manager to their staff. Care Management Plus advocates will assist clinics as they assess their use of their EHR systems and redesign care processes to optimize the use of an onsite care manager.

Use By Other Organizations