Effectiveness of Outpatient Case Management for Adults With

Effectiveness of Outpatient Case Management for Adults With Medical Illness and Complex Care Needs Prepared for: Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov

Outline of Material Introduction to case management (CM) programs and the conditions they target Systematic review methods The clinical questions addressed by the comparative effectiveness review Results of studies and evidence-based conclusions about the effectiveness of CM programs for patients with chronic conditions and complex care needs Gaps in knowledge and future research needs What to discuss with patients and their caregivers Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Background: Chronic Illness Care and Case Management Chronic diseases are the leading cause of illness, disability, and death in the United States. For patients with chronic illnesses, health care resources generally are available but may be inaccessible or poorly coordinated. One strategy for improving the effectiveness of care for chronic illnesses is to develop programs that enhance coordination and implementation of care plans. Case management is one such service in which a person, usually a nurse or social worker, coordinates and implements a patient’s care plan. The case manager might work alone or in conjunction with a team of health professionals. The evolution of care models in health care has led to the use of the term “case management” to describe a wide variety of interventions. Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Background: Functions of a Case Manager In chronic illness care, while clinical functions are central to the role of a case manager, he or she also performs coordinating functions. Clinical functions of a case manager include: Disease-oriented assessment and monitoring Medication adjustment Health education Self-care instructions The distinct but complementary coordinating functions performed by a case manager include: Helping patients navigate health care systems Connecting patients with community resources Orchestrating multiple facets of health care delivery Assisting with administrative and logistical tasks Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Background: Roles of a Case Manager Within a Health Care Organization Depending on the health care organization, the case manager can play distinctly different roles: A care provider who helps patients to improve their selfmanagement skills and/or helps caregivers to be more effective in supporting patients A collaborative member of the care delivery team who promotes better communication with providers and advocates for implementation of care plans A patient advocate who evaluates patient needs and works to surmount problems with access to clinical services Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Background: Challenges Related to Evaluating the Effectiveness of Case Management Programs Individual case management (CM) programs are often customized for the clinical issues of the population they serve. A CM program for homeless people with AIDS has a different mix of activities than a program for patients with dementia and their caregivers. Some CM programs target patients with specific characteristics, while others serve unselected populations with a chronic illness. CM interventions may be intensive and involve frequent contact or may entail only infrequent contact. This variability in CM interventions makes evaluation of the effectiveness of CM programs challenging. Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Addressing the Challenges Related to Evaluating the Case Management Programs in This Review Given the substantial heterogeneity of purposes, approaches, and populations within the broad category of case management (CM) programs, the scope of this review was limited in several ways including: Inclusion of CM programs where case managers had a combination of clinical and coordinating functions Inclusion of CM programs that targeted chronic medical illnesses only Restriction of the review to CM programs that involved a sustained relationship between the case manager and patient Evaluation of patients in outpatient settings only Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review (CER) Development Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others. A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment. The results of these reviews are summarized into Clinician Research Summaries and Consumer Research Summaries for use in decisionmaking and in discussions with patients. The Research Summaries and the full report, with references for included and excluded studies, are available at www.effectivehealthcare.ahrq.gov/case-management.cfm. Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Clinical Questions Addressed by This Comparative Effectiveness Review (1 of 2) Key Question 1. In adults with chronic medical illnesses and complex care needs, is case management effective in improving: a. Patient-centered outcomes, including mortality, quality of life, disease-specific health outcomes, avoidance of nursing home placement, and patient satisfaction with care? b. Quality of care, as indicated by disease-specific process measures, receipt of recommended health care services, adherence to therapy, missed appointments, patient selfmanagement, and changes in health behavior? c. Resource utilization, including overall financial cost, hospitalization rates, days in the hospital, emergency department use, and number of clinic visits (including primary care and other provider visits)? Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Clinical Questions Addressed by This Comparative Effectiveness Review (2 of 2) Key Question 2. Does the effectiveness of case management differ according to patient characteristics, including but not limited to: particular medical conditions, number or type of comorbidities, patient age and socioeconomic status, social support, and/or level of formally assessed health risk? Key Question 3. Does the effectiveness of case management differ according to intervention characteristics, including but not limited to practice or health care system setting; case manager experience, training, or skills; case management intensity, duration, and integration with other care providers; and the specific functions performed by case managers? Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Rating the Strength of Evidence From the Comparative Effectiveness Review The strength of evidence was classified into four broad categories: Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Multiple Chronic Illnesses (1 of 2) Patient Experience Outcomes CM programs increased the perception of patients that their care was better coordinated. Strength of Evidence: High Clinical Outcomes CM programs did not improve functional status or overall mortality. Strength of Evidence: High Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Multiple Chronic Illnesses (2 of 2) Resource Utilization Outcomes Case management (CM) programs did not reduce overall hospitalization rates. Strength of Evidence: Moderate CM programs were more effective for preventing hospitalizations when case managers had greater personal contact with patients and physicians. Strength of Evidence: Low CM programs were more effective for reducing hospitalization rates among patients with greater disease burden. Strength of Evidence: Low CM programs did not reduce Medicare expenditures. Strength of Evidence: High Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Frail Elderly Patients Clinical Outcomes Case management (CM) programs did not affect mortality. Strength of Evidence: Low Resource Utilization CM programs did not reduce nursing home admissions or acute hospitalizations. Strength of Evidence: Low Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Dementia (1 of 2) Patient Experience Outcomes Case management (CM) programs reduced caregiver depression at 2 years and caregiver burden at 12 months. Strength of Evidence: Moderate Quality of Care Outcomes CM programs increased adherence to clinical guidelines for dementia care when focused on those guidelines . Strength of Evidence: Low Resource Utilization Outcomes CM programs did not result in reduction in health care expenditures at 12 months. Strength of Evidence: Moderate Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Dementia (2 of 2) Clinical Outcomes Case management (CM) programs delayed nursing home placement of patients with dementia who have in-home spouse caregivers when program duration was longer than 2 years. Strength of Evidence: Low CM programs did not result in significant delays in nursing home placement if the programs had a duration of 2 years or less. Strength of Evidence: Moderate CM programs did not lower mortality rates. Strength of Evidence: High CM programs did not result in changes in the behavioral symptoms of patients. Strength of Evidence: Moderate Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Congestive Heart Failure (1 of 2) Patient Experience Outcomes Case management (CM) programs increased patient satisfaction. Strength of Evidence: Moderate Quality-of-Care Outcomes CM programs increased patient adherence to recommended disease self-management behaviors. Strength of Evidence: Moderate CM programs were more effective in improving patient outcomes when case managers were a part of a multidisciplinary team of health care providers. Strength of Evidence: Low Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Congestive Heart Failure (2 of 2) Clinical Outcomes Case management programs improved quality of life but did not affect mortality. Strength of Evidence: Low Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Diabetes Clinical Outcomes Case management (CM) programs improved glucose control. Strength of Evidence: Low CM programs did not improve management of lipids or weight/body mass index. Strength of Evidence: Moderate CM programs were not effective at reducing mortality. Strength of Evidence: Low Resource Utilization Outcomes CM programs were not effective at reducing hospitalization rates. Strength of Evidence: Low Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Serious Chronic Infections Quality-of-Care Outcomes Case management (CM) programs improved rates of successful treatment for tuberculosis in vulnerable populations who were in short-term programs that emphasized medication adherence. Strength of Evidence: Moderate Clinical Outcomes CM programs did not improve survival among patients with HIV infection. Strength of Evidence: Low Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Cancer (1 of 2) Patient Experience Outcomes Case management (CM) programs improved patient satisfaction with care. Strength of Evidence: Moderate Quality-of-Care Outcomes CM programs were effective in increasing the receipt of appropriate (guideline-recommended) cancer treatment. Strength of Evidence: Moderate CM programs were more effective when: The intensity and duration of the intervention was greater The program was integrated with patients’ usual care providers The interventions were structured through preintervention training and care protocols Strength of Evidence: Low Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Cancer (2 of 2) Clinical Outcomes Case management (CM) programs were effective in improving selected cancer-related symptoms and functioning (physical, psychosocial, and emotional) but did not improve overall quality of life or survival. Strength of Evidence: Low Resource Utilization Outcomes CM programs had little effect on overall health care utilization and cost of care. Strength of Evidence: Low„„„ Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Other Clinical Conditions Resource Utilization Outcomes Case management programs reduced emergency department visits among patients with chronic obstructive pulmonary disease and among homeless people. Strength of Evidence: Low„„„„„„ Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Additional Information Based on the range of interventions reviewed, the types of patients who potentially could benefit from case management include: Patients with life-threatening chronic diseases—such as congestive heart failure or HIV infection—that can be improved with proper treatment Patients with progressive, debilitating, and often irreversible diseases—such as dementia or multiple chronic diseases in the aged—for which supportive care can enhance independence and quality of life Patients with progressive chronic diseases (e.g., diabetes mellitus) for which self-management can improve health and functioning Patients for whom serious social problems (e.g., homelessness) impair their ability to manage disease Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Conclusions (1 of 3) Overall, the case-management interventions tested in the reviewed studies were associated with small changes in patient-centered outcomes, quality of care, and health careresource utilization. Specific findings of this review included: Case management tends to improve patient satisfaction with care for some conditions (congestive heart failure [CHF] and cancer) and increase patient perception of care coordination (for multiple chronic illnesses). Case management improves the quality of care, particularly for illnesses that require complex treatments (CHF, tuberculosis, and cancer). Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Conclusions (2 of 3) Other specific findings of this review included: For some medical conditions (congestive heart failure and tuberculosis), case management improves patients’ medication adherence and selfmanagement skills. Case-management interventions showed mixed results in improving patients’ quality of life and functional status. For the caregivers of patients with dementia, targeted case-management programs improve levels of stress, burden, and depression. Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Conclusions (3 of 3) While low-level evidence suggested that case management can improve some types of health care utilization in patients with multiple chronic illnesses who have greater disease burden and chronic homelessness, the effects of case management on health care-resource utilization and on costs of care are minimal. Low-level evidence also showed that case management produces better outcomes when it is characterized by: Intense programs with greater contact time Longer duration of interventions Integration of programs with patients’ usual care providers Incorporation of training protocols in the interventions Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Gaps in Knowledge (1 of 3) Published trials evaluating the effectiveness of case management (CM) in various patient populations have the following limitations: A lack of effective risk-assessment tools for choosing candidates for CM to determine which patients achieve the greatest benefits from CM A paucity of information on how the effectiveness of CM programs varies with patient characteristics A lack of a uniform, consensus definition for CM A lack of comparisons of CM with other types of interventions Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Gaps in Knowledge (2 of 3) Other limitations in the trials evaluating the effectiveness of case management (CM) in various patient populations include: Little or no information about the extent to which CM programs are integrated with the usual source of care Imprecision about the intensity of CM A lack of understanding of the correlation between CM duration and benefits achieved These limitations should be addressed in future studies of CM. Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Gaps in Knowledge (3 of 3) Other elements of case management that should be explicitly described in future research include: Experience level of case managers Training received by case managers Specific functions of case managers and the distribution of effort devoted to different activities Use of protocols, guidelines, and information technology Modes of patient contact Average caseload„„ Relationship to other health care providers Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

What To Discuss With Your Patients and Their Caregivers (1 of 3) What case management (CM) is and that the option of involving a case manager in the management of the patient’s medical condition might exist, depending on the patient’s specific medical condition(s) and health care plan Whether the case manager will meet with the patient at his/her home, in your office, or by phone and the frequency of the meetings The potential duration for which the case manager might work with the patient That a case manager will work with the patient’s health care team, although the level of interaction might vary depending on the type of CM program available to the patient Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

What To Discuss With Your Patients and Their Caregivers (2 of 3) That a case manager can be an advocate who evaluates the patient’s needs and works to surmount problems with access to clinical services How case management might affect the patient’s experience of care (patient satisfaction) The available evidence for the effectiveness of case management in improving quality-of-care outcomes (such as receipt of guideline-recommended clinical services, medication adherence, and attending health care appointments) Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

What To Discuss With Your Patients and Their Caregivers (3 of 3) The available evidence for the effectiveness of case management in improving patient-related outcomes (quality of life, ability to stay at home, and health-related outcomes such as mortality and disease symptoms) or caregiver outcomes (such as stress and depression), given the patient’s specific medical condition(s) The available evidence for the effectiveness of case management in improving health care-resource utilization outcomes (such as hospitalization rates, health care costs, and physician and/or emergency department visits) Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.