The effect of accurate patient screening on the cost-effectiveness of case management programs.

Case management programs are expensive and therefore require careful screening of enrollees to ensure cost-effectiveness. Screening tools, however, are imperfect, with positive predictive values usually below 50%. This article examines the relationship between the accuracy of the screening tools and the cost-effectiveness of case management. Using data from a Medicare health maintenance organization (HMO), we develop an optimized 5-question screening tool. We then simulate the use of this screening tool and its impact on the cost-effectiveness of several hypothetical case management programs. The article demonstrates that even screening tools with only 20-30% positive predictive value could turn a case management program into a cost-effective program.

Rates, patterns, causes, and costs of hospitalization of nursing home residents: a population-based study.

OBJECTIVES: Hospitalization of nursing home residents is a growing, poorly defined problem. The purposes of this study were to define rates, patterns, costs, and outcomes of hospitalizations from nursing homes and to consider implications for reducing this problem as part of health care reform. METHODS: Communitywide nursing home utilization review and hospital discharge data were used to define retrospectively a cohort of 2120 patients newly admitted to nursing homes; these patients were followed for 2 years to identify all hospitalizations. Resident characteristics were analyzed for predictors of hospitalization. Charges and outcomes were compared with hospitalization of community-dwelling elders. RESULTS: Hospitalization rates were strikingly higher for intermediate vs skilled levels of care (566 and 346 per 1000 resident years, respectively). Approximately 40% of all hospitalizations occurred within 3 months of admission. No strong predictors were identified. Length of stay, charges, and mortality rates were higher than for hospitalizations from the community. CONCLUSIONS: Hospitalizations from nursing homes are not easily predicted but may in large part be prevented through health care reforms that integrate acute and longterm care.

Computer-based vs manual health maintenance tracking. A controlled trial.

OBJECTIVE: To compare computer-based with manual health maintenance tracking systems to determine whether (1) a computer-based system will result in better provider compliance with the practice health maintenance protocol, (2) the incremental cost of operating a computer-based vs a manual health maintenance tracking system differs, and (3) inactive patients will respond to health maintenance reminders. DESIGN: Two-year prospective, randomized, controlled trial. SETTING: Rural, multiple-office, nonprofit, fee-for-service family practice. PATIENTS: Adult members of families in which at least one member had been seen by the practice within the past 2 years. INTERVENTION: A computer-based health maintenance tracking system that generated annual provider and patient reminders for all patients regardless of appointment status compared with a manual flowchart-based tracking system in which patient reminders were triggered by provider request. OUTCOME MEASURES: Provider compliance with the health maintenance protocol determined by preintervention and postintervention chart audits, costs of computer-based tracking, and response of inactive patients to health maintenance reminders. RESULTS: Overall provider compliance with the health maintenance protocol increased 15 percentage points in the computer-based tracking group and four percentage points in the manual group. The computer-based tracking group had significantly higher provider compliance than the manual group for eight of 11 procedures. The computer-based tracking system cost 78 cents per patient per year to operate. It was not associated with increased office visits or patient billings. CONCLUSIONS: Computer-based health maintenance tracking improved provider health maintenance compliance compared with a manual system. The finding that health maintenance compliance improved without a significant increase in patient visits or billings requires confirmation in other settings but suggests that considerable health maintenance can be incorporated into ongoing patient care.

Nursing home medical directors: ideals and realities.

OBJECTIVE: To evaluate what nursing home medical directors actually do, what they and other nursing home personnel believe would be desirable to do, and what problems and deficiencies are perceived. DESIGN: Mail survey with follow-up telephone interview when necessary. SETTING: Forty-five nursing facilities in upstate New York. PARTICIPANTS: The medical directors, administrators, and directors of nursing of the 45 facilities. MEASUREMENTS: Inventory of what medical directors reported as to their actual activities and time spent, and of what they, the administrators, and the directors of nursing felt should be their responsibilities and activities under ideal circumstances. RESULTS: For part-time medical directors, self-reported time spent on medical directorship activities averaged 12 hours per month; of all directors, 45% spent 8 hours or less per month. Proportion of time spent on various specific activities varied widely. There was general agreement that substantially more time should be spent, in particular, on evaluating and addressing problems of adequacy and quality of care, communicating with attending physicians about problems, and assisting with inservice training programs. CONCLUSIONS: To fill the role adequately, more time should be spent by many part-time medical directors, which will require greater financial commitment by facilities and reimbursement systems. Efforts need to made to better coordinate the expectations of medical directors and facility staff.

Case management: a randomized controlled study comparing a neighborhood team and a centralized individual model.

This randomized controlled study compared two types of case management for skilled nursing level patients living at home: the centralized individual model and the neighborhood team model. The team model differed from the individual model in that team case managers performed client assessments, care planning, some direct services, and reassessments; they also had much smaller caseloads and were assigned a specific catchment area. While patients in both groups incurred very high estimated health services costs, the average annual cost during 1983-85 for team cases was 13.6 percent less than that of individual model cases. While the team cases were 18.3 percent less expensive among "old" patients (patients who entered the study from the existing ACCESS caseload), they were only 2.7 percent less costly among "new" cases. The lower costs were due to reductions in hospital days and home care. Team cases averaged 26 percent fewer hospital days per year and 17 percent fewer home health aide hours. Nursing home use was 48 percent higher for the team group than for the individual model group. Mortality was almost exactly the same for both groups during the first year (about 30 percent), but was lower for team patients during the second year (11 percent as compared to 16 percent). Probable mechanisms for the observed results are discussed.

Description of a computerized health maintenance tracking system for primary care practice.

This article describes the development of a computerized health maintenance tracking system for primary care practice and its features. Research has shown existing computerized health maintenance tracking systems are unsatisfactory for the average practitioner for these reasons: (1) Data entry is slow or requires duplication of entries for billing purposes; (2) the system is linked to a totally computerized medical record that is expensive and complex to maintain; (3) health maintenance status options are limited to "YES/NO" and do not inform the practitioner of the full range of possible situations; (4) physician reminders are created only for patients with an appointment; (5) patient reminders are not generated on a regular basis regardless of appointment status; (6) it is difficult to change individual and global health maintenance schedules. The system described here downloads demographic and health maintenance data from the practice's billing system. Six health maintenance status options are available: D = done and normal, X = done but abnormal, N = not indicated, R = patient refused, E = done elsewhere, I = abnormal but inactive. A health maintenance status report is created for both the patient and provider once a year, in the month of the patient's birth unless an alternate month has been designated, regardless of the patient's appointment status. Patients are encouraged to make an appointment for overdue health maintenance procedures, unless already scheduled.

Physician response to notification of acute problems in nursing homes.

A frequently cited example of physicians' alleged disinterest in nursing home patients is their failure to respond rapidly or appropriately to telephone calls about acute events or important changes in patient status. This study of 45 SNFs and their 15 attached ICFs evaluated the length of time required to reach physicians by phone about significant clinical changes in patients' conditions and the appropriateness and timeliness of action taken by the physicians once contact was made. Calls on administrative matters, updating of orders, and similar routine calls were excluded. Seven hundred and fifty calls were identified from 24-hour nursing reports; the nature of the problem and the time and details of physicians' responses were recorded from patient charts. Judgment on the quality of physicians' responses was made by consensus of the regional UR committee except in the case of infections where decisions were based on detailed criteria developed in a previous study. The most frequent clinical problems were acute infections (32%), trauma (12%), GI tract disorders (11%), cardiorespiratory problems (10%), neurological disorders (7%), and diabetic control (7%). Results were very encouraging: 96% of physicians' call-backs and actions were judged to be timely, and 87% of physicians' actions taken were judged to be appropriate. However, actions taken were judged inappropriate for certain specific clinical problems, ie, in 22% (54/243) of infections, 24% (4/17) of CVA's, and 12% (6/49) of diabetic control problems. Implications for nursing home care and recommendations for improving the response to acute problems are discussed.

Individual versus team case management in optimizing community care for chronically ill patients with dementia.

Secondary analyses of a randomized trial comparing two models of case management of community residing chronically ill elderly showed that the greatest cost savings of the more intensive neighborhood-based team model, as opposed to the centralized individual model, were in the group with dementia. Estimated costs of health care in the team group were 41% lower than costs for the control group. No differences in survivorship, functional and care need status, or in caregiver satisfaction were found, suggesting no negative effect of reduction in use. Team case managers had much smaller caseloads, made many more home visits, (with much more counseling for family support), and made more referrals for medical evaluation, respite, and day care than did case managers for the control group.

Nursing homes as acute care providers. A pilot study of incentives to reduce hospitalizations.

This program was designed to encourage treatment of episodes of acute illness in skilled nursing facilities in order to avoid costly and potentially traumatic admission to hospital. It is part of the Monroe County Long Term Care Program, Inc, system of case management and Medicare and Medicaid waivers, and consists of financial incentives, paid by Medicare, to facilities and to responsible physicians to evaluate and care for acutely ill patients in the SNF's when medically safe and feasible. A retrospective evaluation using a physician assessment committee concluded that among the first 112 patients in the program, 76% were very probably saved hospitalization or at least an emergency room visit. Acute bacterial infection was the most common category of episode, occurring in 46% of cases. Considerable savings to both Medicare and Medicaid were estimated to have resulted.

How does the team approach to outpatient geriatric evaluation compare with traditional care: a report of a randomized controlled trial.

Although team-oriented geriatric assessment clinics are growing throughout the country, little documentation exists regarding their clinical efficacy, cost-effectiveness, or impact on patient functioning and well-being. This report describes a randomized controlled clinical trial to evaluate the effectiveness of a team-oriented geriatric assessment approach compared to traditional care. One hundred-seventeen subjects 65 years of age and over, meeting eligibility criteria to target frail older persons with changing medical and social needs, were randomly assigned to receive a comprehensive geriatric assessment by a multidisciplinary team (treatment) or by one of a panel of community internists who were reimbursed according to their usual and customary fee (controls). Extensive analysis of baseline information failed to identify any significant differences between groups. Over the 1-year follow-up period, treatment participants experienced 26 hospital admissions and used 670 hospital days compared with 23 admissions and 1113 days for controls (a 39.8% difference). Annual hospital costs averaged $4297 for treatment subjects and $7018 for controls. Overall institutional costs including hospital and nursing home care revealed an average saving of $2189 per person for treatment subjects compared with controls, a 25% reduction. A small proportion of subjects accounted for this difference. No significant differences were noted in patient or caregiver satisfaction with the evaluation process, functional ability, or health status. These findings suggest that team-oriented outpatient geriatric assessment provides a promising way to deliver high-quality, satisfying care to older persons without increasing (and possibly decreasing) health care costs.

Systemic antibiotic use in nursing homes. A quality assessment.

In this evaluation of the prevalence and quality of systemic antibiotic use in nursing homes, 42 skilled nursing facilities (SNFs) and their 11 attached intermediate care facilities (ICFs) were surveyed. A random sample of 2238 patients (51%) from the total of 4378 beds was selected and of these, 7.7% of the total (8.6% of the SNF and 4.5% of the ICF) patients were on systemic antibiotics on the day of the survey. The most common suspected sites of infection were urinary tract (58.4%), lower respiratory tract (19.1%), and skin or subcutaneous tissue (4.6%). Criteria for appropriateness of initiating systemic antibiotics, for adequacy of initial diagnostic workup, and for appropriate specific antibiotics were developed by the authors, with input from a group of medical directors of nursing homes, based on Centers for Disease Control and Federal Drug Administration guidelines. Evidence to start an antibiotic was judged adequate in 62.4% of cases. Workups were considered inadequate in a high proportion of cases. For example, urinalysis was ordered in only 23.8% and urine culture in 57.4% of suspected urinary tract infections; chest x-ray was ordered in 24.2% and sputum culture in 3.0% of suspected lower respiratory infections. Recommendations are made as to minimum adequate workup for suspected infections and appropriate evidence to justify start of a systemic antibiotic, recognizing the limitations in diagnostic modalities in the nursing home setting and the special problems of their resident populations.

Geriatric consultation teams in acute hospitals: impact on back-up of elderly patients.

Back-up of elderly patients in hospital awaiting long-term placement has become a major problem in some areas of the United States and elsewhere. In 1982, geriatric consultation teams (physician, nurse, and social worker) were introduced into six acute hospitals in Monroe County, New York, to help alleviate the problem through more attention to restoration of patient function and comprehensive discharge planning. Over a six-month period, 4,328 newly hospitalized patients aged 70 or older were screened, and geriatric consultations were provided for 366 (8.5 per cent) who were judged to be at risk of requiring prolonged hospital stays. During this period, the mean monthly census of elderly patients backed up in hospital declined 21 per cent, a reversal of previous rises that could not be explained by any other identifiable factors. The impact was on length of stay on back-up status rather than rate of entry to that status. A variety of medical, rehabilitative, and social interventions accounted for this outcome. A number of health care system barriers to expeditious rehabilitation and discharge of hospitalized elderly patients were identified. Geriatric consultation was deemed useful for implementation in acute hospitals in other settings.

A randomized controlled study of a home health care team.

This report describes the findings of a randomized study of a new team approach to home care for homebound chronically or terminally ill elderly. The team includes a physician, nurse practitioner, and social worker delivering primary health care in the patient's home, including physician house calls. Weekly team conferences assure coordination of patient care. The team is available for emergency consultation through a 24-hour telephone service. The team physician attends to the patient during necessary hospitalizations. This approach was evaluated in a randomized experimental design study measuring its impact on health care utilization, functional changes in patients, and patient and caretaker satisfaction. The team patients had fewer hospitalizations, nursing home admissions, and outpatient visits than the controls. They were more often able to die at home, if this was their wish. As expected, they used more in-home services, measured in weighted cost figures; their overall cost was lower than their controls, but the difference was not statistically significant. Their functional abilities did not change differently from the controls, but they, and especially their informal caretakers in the home, expressed significantly higher satisfaction with the care received.

Behavioral problems among patients in skilled nursing facilities.

This survey of a 33 per cent random sample (1,139) of 3,456 patients in 42 skilled nursing facilities (SNFs) in upstate New York yielded 64.2 per cent with significant behavioral problems. Of these, 257 (22.6 per cent) of the total sample had what were defined as "serious" problems (i.e., excluding those with only impaired judgment and/or physical restraint orders). Details of the problem behaviors of this group, their previous history, current management, frequency of psychiatric consultation, and adequacy of documentation were analyzed. Median age was the same as the general SNF population, a slightly lower proportion was female, and, while 66.5 per cent had diagnoses indicating organic brain syndrome, very few had specific psychiatric diagnoses, and only 4.7 per cent had been admitted from a psychiatric facility. The attending physician had noted the behavioral problem in the record in only 9.7 per cent and had requested psychiatric consultation in 14.8 per cent of these "serious" cases. The need for more staff training in mental health care, and more physician and psychiatric consultative assistance are discussed.

Effects of a physician-led home care team on terminal care.

Inconsistent results in studies of cost-effectiveness of home health care have led to the need for identification of target populations for whom cost-savings can be anticipated if expanded home care programs are introduced. This analysis of results of a randomized controlled study of efficacy of a physician/geriatric nurse practitioner/social worker home care team identifies such a potential target population. The team provides round-the-clock on-call medical services in the home when needed, in addition to usual nursing and other home care services, to home-bound chronically or terminally ill elderly patients. Overall health services utilization and estimated costs were not substantially different for the patients who did not die while in the study; however, for those who did die, team patients had considerably lower rates of hospitalization and overall cost than controls, and more frequently died at home. Of 21 team and 12 control patients who died but had at least two weeks of utilization experience in the study, team patients had about half the number of hospital days compared with controls during the terminal two weeks, and although they had more home care services, had only 69 per cent of the estimated total health care costs of the controls. Satisfaction with care received was significantly greater among the total group of team patients, and especially among their family caretakers, than among controls. This model is effective in providing appropriate medical care for seriously ill and terminal patients, and in enabling them to die at home if they so wish, while at the same time reducing costs of care during the terminal period.

Quality of care assessment in long-term care facilities.

Quality of care assessment is in a rather rudimentary state of development in most long-term health care settings. Some of the mandates and initiatives in this area of evaluation are described and discussed. A few caveats are presented and suggestions made as to appropriate approaches to quality assessment in chronic care facilities, which are different in many respects from the more traditional approaches used in acute care hospitals. Of particular importance, and at the same time of greatest difficulty, is the assessment of quality of life in institutions where many patients spend the remainder of their lives.

A time-motion study of patient care activities of a geriatric home care team.

A self-administered time-motion study of the activities of a home care team, consisting of physician, nurse practitioner and social worker is reported. The patients were home-bound, chronically or terminally ill and largely elderly, and the physician and nurse practitioner were available by telephone and for emergency visits on a 24-hour, 7 day per week basis. A systematic sample of 24 hour calendar days was studied; the average team patient census was 54 (the team had other clinical responsibilities in addition). Time spent on travel, home visits and on team conferencing and consultation was higher than in other practices, as might be expected. Full-time equivalent requirements for this type of care program were extrapolated to come to approximately one physician and social worker and one and one-half nurse practitioner per 100 patients. A truer estimate of actual costs of provision of team services to home-bound patients can be provided by this method than by the usual calculation of charges based only on actual home visits.