Older patients with multiple chronic conditions often see multiple physicians and frequently receive health care from the emergency department or hospital. In the first step of this PCORI health systems demonstration, health systems leaders across the country suggested that researchers should figure out the best ways to identify and support these patients who are interacting frequently with the health system. Care for these patients is often poorly coordinated and it can be unclear which physician is responsible for what. One model to improve care for these patients is case management, in which a nurse or social worker works directly with the patient to coordinate a care plan across many different physicians. There is still uncertainty over what the most important elements of these case management programs are or which patients are most likely to benefit from participating.
Teams from University of Wisconsin-Madison, Massachusetts General Hospital/Harvard University, and the University of Iowa will partner to identify the most important parts of case management programs in health systems across the country, and to look at their own case management programs in more detail. Our project will help health systems understand how to design case management programs to support older patients who interact frequently with health systems and to build the capacity of our PCORI networks to address questions of interest to local participating health systems.
First, we will characterize case management programs across the 22 health systems participating in two PCORI networks (Greater Plains Collaborative and Scalable Collaborative Infrastructure for a Learning Health System). We will conduct interviews of patients, health system leaders, and program directors to develop a survey instrument, followed by a comprehensive survey of program directors that catalogs program elements.
Second, we will examine the extent to which existing case management programs at our three health systems prevent hospital events (hospital admissions, observation stays, and emergency department visits) for patients enrolled in Medicare accountable care organizations (ACOs). We will measure the rate of hospital events over time for each case management patient and a similar patient who did not receive case management.
We will engage patients, clinician champions, and health systems leaders in all aspects of the study—from design and conduct to dissemination of results. Our patient partners and stakeholders will help develop the survey that seeks to characterize individual case management programs. They will also help interpret our findings, identify how to share our findings so that patients, families, and health systems are aware of the results, and develop the agenda for a face-to-face meeting of the entire study team, patient partners, physician champions, and case management directors/health systems leaders from the 22 health systems to review the results and organize next steps.
Individuals with Disabilities
Individuals with Multiple Chronic/co-morbid Conditions