Obstacles Experienced by Care Managers in Managing Information for the Care of Chronically Ill Patients.

Care managers play a key role in coordinating care, especially for patients with chronic conditions. They use multiple health information technology application in order to access, process and communicate patient-related information. Using the work system model and its extension, the SEIPS model (Carayon et al., 2006a; Smith and Carayon-Sainfort, 1989), we describe obstacles experienced by care manager in managing patient-related information. A web-based questionnaire was used to collect data from 80 care managers (61% response rate) located in clinics, hospitals and a call center. Care managers were more likely to consider 'inefficiencies in access to patient-related information' and 'having to use multiple information systems' as major obstacles than 'lack of computer training and support' and 'inefficient use of case management software.' Care managers who reported inefficient use of software as an obstacle were more likely to report high workload. Future research should explore strategies used by care managers' to address obstacles, and efforts should be targeted at improving the health information technologies used by care managers.

Perceived Impact of Care Managers' Work on Patient and Clinician Outcomes.

OBJECTIVES: The aim of this study is to assess the contributions of care management as perceived by care managers themselves. STUDY DESIGN: Focus groups and interviews with care managers who coordinate care for chronic obstructive pulmonary disease and congestive heart failure patients, as well as patients undergoing major surgery. METHODS: We collected data in focus groups and interviews with 12 care managers working in the Keystone Beacon Community project, including 5 care managers working in hospitals, 2 employed in outpatient clinics and 4 telephoning discharged patients from a Transitions of Care (TOC) call center. RESULTS: Inpatient care managers believe that (1) ensuring primary care provider follow-up, (2) coordinating appropriate services, (3) providing patient education, and (4) ensuring accurate medication reconciliation have the greatest impact on patient clinical outcomes. In contrast, outpatient and TOC care managers believe that (1) teaching patients the signs and symptoms of acute exacerbations and (2) building effective relationships with patients improve patient outcomes most. Some care management activities were perceived to have greater impact on patients with certain conditions (e.g., outpatient and TOC care managers saw effective relationships as having more impact on patients with COPD). All care managers believed that relationships with patients have the greatest impact on patient satisfaction, while the support they provide clinicians has the greatest impact on clinician satisfaction. CONCLUSIONS: These findings may improve best practice for care managers by focusing interventions on the most effective activities for patients with specific medical conditions.

Can telemonitoring reduce hospitalization and cost of care? A health plan's experience in managing patients with heart failure.

Telemonitoring provides a potentially useful tool for disease and case management of those patients who are likely to benefit from frequent and regular monitoring by health care providers. Since 2008, Geisinger Health Plan (GHP) has implemented a telemonitoring program that specifically targets those members with heart failure. This study assesses the impact of this telemonitoring program by examining claims data of those GHP Medicare Advantage plan members who were enrolled in the program, measuring its impact in terms of all-cause hospital admission rates, readmission rates, and total cost of care. The results indicate significant reductions in probability of all-cause admission (odds ratio [OR] 0.77; P<0.01), 30-day and 90-day readmission (OR 0.56, 0.62; P<0.05), and cost of care (11.3%; P<0.05). The estimated return on investment was 3.3. These findings imply that telemonitoring can be an effective add-on tool for managing elderly patients with heart failure.

Advancing the role of nursing in the medical home model.

The patient-centered primary care model has been positioned to improve patient outcomes, enhance patient satisfaction, and reduce health care costs. The role of nursing in this care transformation is evident in ProvenHealth Navigator-one of the organization's primary care models. ProvenHealth Navigator incorporates primary care practice redesign, including team-delivered care, as the foundation for its model. Case managers, as one of the components of the care team, have demonstrated their value in reducing fragmentation, enhancing care transitions, and coordinating care for the most complex patients.Combining the strengths of a clinical delivery system with the population management expertise of a health plan, ProvenHealth Navigator capitalizes on the strengths of an integrated health care system to stratify the population, enhance access, optimize outpatient treatment, provide near real-time reporting, and deploy additional disease/case management resources for those most in need of additional health care services. Operational since 2006, ProvenHealth Navigator has been associated with significant reductions in all-cause admissions, readmissions, and total cost of care. In addition, quality indicators for chronic conditions and preventive care improved and patient and clinician satisfaction is high. Optimizing the role of primary care teams and focusing on population management services provides one method of improving quality and reducing costs thus increasing health care value.

Postdischarge monitoring using interactive voice response system reduces 30-day readmission rates in a case-managed Medicare population.

BACKGROUND: Automated home monitoring systems have been used to coordinate care to improve patient outcomes and reduce rehospitalizations, but with little formal study of efficacy. The Geisinger Monitoring Program (GMP) interactive voice response protocol is a post-hospital discharge telemonitoring system used as an adjunct to existing case management in a primary care Medicare population to reduce emergency department visits and hospital readmissions. OBJECTIVES: To determine if use of GMP reduced 30-day hospital readmission rates among case-managed patients. RESEARCH DESIGN: A pre-post parallel quasi-experimental study. METHODS: A total of 875 Medicare patients who were enrolled in the combined case-management and GMP program were compared with 2420 matched control patients who were only case managed. Claims data were used to document an acute care admission followed by a readmission within 30 days in the preintervention and postintervention periods (ie, before and during 2009). Regression modeling was used to estimate the within-patient effect of the intervention on readmission rates. RESULTS: The use of GMP with case management was associated with a 44% reduction in 30-day readmissions in the study cohort (95% confidence interval, 23%-60%, P=0.0004), when using the control group to control for secular trends. Similar estimates were obtained when using different propensity score adjustment methods or different approaches to handling dropout observations. CONCLUSIONS: Investing in automated monitoring systems may reduce hospital readmission rates among primary care case-managed patients. Evidence from this quasi-experimental study demonstrates that the combination of telemonitoring and case management, as compared with case management alone, may significantly reduce readmissions in a Medicare Advantage population.