SummaryThe Care Management Plus program combines the care coordination services of a care manager with robust electronic tracking and reminder systems to deliver comprehensive medical care to seniors with multiple chronic illnesses in primary care clinics. The care manager helps patients and their caregivers manage a wide spectrum of medical and quality-of-life issues that may involve coordination with physicians, specialists, and community resources. The informatics tools document the care plan and provide reminders on appropriate best practices. In initial studies, the program was effective in reducing costs and improving outcomes for patients, including better blood sugar control and fewer complications, hospitalizations, and deaths for diabetes patients.Moderate: The evidence consists of post-implementation comparisons of care-managed patients to a control group on selected clinical outcomes, costs, and physician productivity.
Developing OrganizationsIntermountain Healthcare; Oregon Health & Science University
Problem AddressedThe current primary care model is better suited to treat single, acute illnesses than the complicated chronic illnesses faced by many older Americans. Primary care physicians often work in systems that force them to treat patients reactively, with short appointments and limited patient instruction, which fails to adequately address the patient’s total health care and quality-of-life needs, especially among the many older adults and others with multiple chronic conditions.
Specific aspects of the problem are detailed below:
- Many older adults with multiple, costly chronic conditions: Sixty-five percent of the Medicare-funded population have 2 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 older 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 older adults and other 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 adequate 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 ActivityThe Care Management Plus program uses care managers equipped with informatics tools in primary care clinics to orchestrate care plans for elderly patients with chronic conditions. The managers work with health care providers, specialists, and community agencies to coordinate and improve patient care and outcomes. At the heart of the Care Management Plus program is an electronic tracking and reminder system. The combination of IT and well-trained care managers helps patients and caregivers self-manage their conditions, prioritize health care needs, prevent complications through structured health care protocols, and navigate an increasingly complex health care system. Key elements of the program are described below:
- Patient referral to a care manager: 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 older adults, 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. Approximately 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.
- 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 pilot 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.
- Connections to 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.
- Use of IT systems: IT systems are used extensively to facilitate and improve teamwork and communication between primary care providers and specialists and to target information appropriate for each specific individual. The IT tools do not act as electronic health records (EHRs), but they can augment and work with existing EHRs, and they can be used in practices that do not have EHRs.
- 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 each clinic 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 examinations 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 IT system 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.
- Patient worksheet: The patient worksheet is automatically generated by the information system (which is integrated with the clinic’s scheduling system) before each visit. The worksheet includes all current diagnoses, allergies, medications, and the care manager’s progress notes, and it provides reminders about needed services, including preventive and screening services that are specific to the chronic conditions of the patient. For example, the worksheet includes reminders about needed vaccinations and tests (e.g., an echocardiogram) for patients diagnosed with heart failure. Because the worksheet contains pertinent clinical data and alerts for up to five chronic illnesses in a single document, it can be reviewed quickly by providers at the point of care, thus integrating easily into existing workflows. In addition to using the worksheet to guide care, clinicians often give it to patients and/or caregivers to supplement other verbal and written directions designed to aid in self-management.
Context of the InnovationIntermountain Healthcare, a national leader in care management, decided in 1995 to extend their hospital care management program to some of their primary care clinics by integrating care managers into their primary care workflow. This approach avoided the expense of creating specialized clinics or holding clinic sessions, or using outside personnel to improve medical care for patients with multiple conditions. The program initially targeted diabetes management, with the care managers focusing primarily on educating and monitoring diabetic patients. Building on the Chronic Care Model, Intermountain expanded the role of care managers to address the needs of patients with multiple chronic conditions as well as mental health and social needs. In 2001, with the support of a John A. Hartford Foundation grant, Intermountain developed informatics tools to specifically support the role of the clinic-based care managers, including transforming an existing diabetes worksheet to address multiple conditions.
ResultsA seven-clinic pilot test showed that the Care Management Plus program was highly effective in enhancing access to needed services, which led to significant improvements in patient outcomes, including fewer complications, deaths, and hospitalizations for diabetes patients. The care manager’s oversight and patient tracking software also increased physician productivity and reduced medical costs, yielding net benefits of roughly $75,000 per case manager.
Moderate: The evidence consists of post-implementation comparisons of care-managed patients to a control group on selected clinical outcomes, costs, and physician productivity.
- 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 threefold greater reductions in glucose levels (hemoglobin A1c levels) compared with 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 more than $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 approximately $175,000 to society in avoided medical costs and increased physician efficiency, or a net benefit of approximately $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.
Planning and Development ProcessKey steps in the development process included:
- Developing job descriptions: The care manager model was developed initially at Intermountain and continued to be refined and expanded at the Department of Medical Informatics and Clinical Epidemiology at Oregon Health and Science University in Portland. The job description for the care manager was 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 inperson and online (8-week) course work. Care managers are encouraged to collaborate with others in the Care Management Plus network to continue learning. This process is facilitated by the Care Manager + Learning Community collaborative for current and potential adoptees designed to provide a resource for best practice sharing in primary care. Monthly care manager technical assistance calls feature a different theme/educational topic along with a guest expert. The second half of each call is a discussion of topics, sharing of concerns, triumphs, or questions, and problem-solving exercises.
- 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. The database that proved crucial to the success of the implementation of this model is currently being adapted into a Web-based application that features enhanced population management and quality improvement instruments, known as the Integrated Care Coordination Information System.
- Pilot testing: During the first year of the pilot program, care management services were pilot tested in 7 clinics, with services provided to 1.7 percent of the 106,766 adult patients seen.
- Program expansion: As of June 2014, the program has been expanded to more than 390 clinics. For each new clinic, a dissemination plan is developed that incorporates multiple facets of implementation, including financial and organizational considerations, referral specifications, IT use and needs, and evaluation processes.
Resources Used and Skills Needed
- Staffing: Each of the 7 care managers are paid roughly $75,000 a year.
- Costs: The training for each care manager is now fee-based. The Care Management Tracking database system is available free of charge on the Care Management Plus Web site. The Web-based application (the Integrated Care Coordination Information System) may be available to clinics for the cost of integrating it with their EHR.
Funding SourcesAgency for Healthcare Research and Quality; National Library of Medicine; California Healthcare Foundation; Intermountain Healthcare; Hartford Foundation; Gordon and Betty Moore Foundation; CareOregon; Medicare Coordinated Care Practice-based Research Network; Aligning Forces for Quality; Children's Health Alliance; O-HITEC; Healthcare Partners; Oregon Community Foundation
The John A. Hartford Foundation provided startup funding for the pilot project through spring 2011. The foundation awarded Oregon Health and Science University a 4-year, $2.5 million grant to expand the Care Management Plus model into 40 rural and urban clinics across the country. As a result, Care Management Plus software is available for free on the program Web site. Fee-based trainings are offered periodically to interested clinics and health systems.
The Agency for Healthcare Research and Quality provided development and study funds for the Integrated Care Coordination Information System, a Web-based tracking program based on the Care Management Plus software, which can more easily exchange information with EHRs and population registries.
Information provided in August 2012 indicates that in May 2011, the California HealthCare Foundation provided $135,000 to Care Management Plus to help prepare care managers and supervisors across the State of California to care for seniors and persons with disabilities. This population was moved into Medi-Cal managed care plans by the State of California as a result of Senate Bill 208. In addition, the Gordon and Betty Moore Foundation has invested $1.6 million to enhance the Care Management Plus program. The new grant will enable the team to develop the program further and ultimately transform delivery of care for those living with multiple chronic conditions.
Tools and Other ResourcesCare Management Plus Web site. Available at: http://www.caremanagementplus.org/.
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. This requires clinic workflow redesign to prioritize the care manager’s time with patients.
Spreading This InnovationPeaceHealth in Oregon and Washington, Healthcare Partners in California, Kaiser Permanente in Oregon, the Veteran’s Administration in Oregon and Washington, EXCELth in New Orleans, LA, and several other health systems have adopted this program. In addition, there is increased international interest in this program. As of June 2014, more than 395 clinics across the country have implemented the program.
Additional ConsiderationsOrganizations interested in implementing this model can receive assistance with both software development and training and supporting care managers through the Care Management Plus team at http://www.caremanagementplus.org/contact.html. Support may include:
- 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 and Science University are 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.
Contact the InnovatorDavid Dorr, MD
Oregon Health & Science University
Department of Medical Informatics & Clinical Epidemiology
3181 SW Sam Jackson Park Rd., Mailcode: MDYMICE
Portland, OR 97239
Phone: (503) 418-2387
Fax: (503) 494-6324
Innovator DisclosuresIn addition to the organizations that have financially supported this program that are listed in the Funding Sources section, Dr. Dorr reported receiving the following payments related to this program:
- Consulting fees and honoraria from the Seamon Corporation, Michigan State University, Portland Veterans Administration, Columbia University, and the University of California (Davis).
- Reimbursement for travel expenses from the Seamon Corporation, Columbia University, University of California (Davis), Senior Care Action Network Centura Health, the National Academy of Engineering, and the Agency for Healthcare Research and Quality (AHRQ).
- Payment from the John A. Hartford Foundation for writing and reviewing a white paper manuscript.
Dorr DA, Wilcox A, Burns L, et al. Implementing a multidisease chronic care model in primary care using people and technology. Dis Manag. 2006;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;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://caremanagementplus.org/publications/Quality%20Insight%20Fall%202006.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;54(4):667-73. [PubMed]
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Dorr DA, Wilcox A, Donnelly SM, et al. Impact of generalist care managers on patients with diabetes. Health Serv Res. 2005;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;56(12):2195-2202. [PubMed]
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Dorr DA, Wilcox A, Donnelly SM, et al. Impact of generalist care managers on patients with diabetes. Health Serv Res. 2005;
40(5 Pt 1):1400-21. [PubMed]
Dorr DA, Wilcox AB, Brunker CP, et al. The effect of technology supported, multidisease case management on the mortality and hospitalization of seniors. J Am Geriatr Soc. 2008;56(12):2195-2202. [PubMed]
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Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 17, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.