There are a lot of ways of slicing and analyzing health spending, but no matter how you do it, one big bucket is costs associated with chronic illness, especially for older Americans. A number of methods for managing the care of these patients have been suggested and tested. The Agency for Healthcare Research & Quality has issued a comparative effectiveness report which examined the literature to ascertain which care management methods appear to be generating good outcomes. (AHRQ Report) The review panel did an exhaustive literature search and found about 76 studies deemed to be of good enough quality to include in the analysis. The studies were often limited to care management of a single disease and used a large variety of interventions.
Care management interventions tend to have two major functions; one is coordinating care, which may include helping patients navigate the system, connecting patients with community resources and ensuring continuity of care; the other function is clinical, the actual monitoring of a patient’s status, adjusting medication and other treatments and educating patients to help them engage in self-care and self-management. The variety of care management programs makes any comparative effectiveness review difficult. The big picture finding was that all of the interventions described and tested in the studies were associated with only small improvements in patient-centered outcomes, quality of care and resource utilization. Those interventions that appeared to have the largest effects include more intense care management interventions with greater amounts of patient contact time, longer duration programs, face-to-face visits and better integration with patients’ usual care providers.
It is perhaps not possible to identify a single or even a couple of care management interventions that are the best for all diseases, patients or circumstances. It may be more possible to identify attributes of interventions that lead to better outcomes, but it may also be that significant tailoring needs to be done for each patient to create the most positive care management intervention for that patient. The only good news is that the overall health spending for many of these patients is so high for so long that it makes it worth providing significant care management programs for them. And one of the clearer findings was that most care management improves patient satisfaction and patient self-care skills and reduces stress on informal caregivers, so the programs likely have benefits from the patient’s perspective.