A study on AHRQ’s Health Care Innovations Exchange web site demonstrates how supporting primary care managers with IT systems helps to deliver care to seniors with multiple chronic illnesses plus reduces costs and improves outcomes. The primary care managers in the study worked with healthcare providers, specialists, and community agencies to coordinate patient care and used an electronic tracking and reminder system.
Before the study began, Intermountain Healthcare, a leader in care management used the Chronic Care Model to expand the role of care managers to address the needs of patients with multiple chronic conditions as well with mental health and social needs. Then the care manager model developed at Intermountain was refined and expanded by the Department of Medical Informatics & Clinical Epidemiology at Oregon Health & Science University (OHSU).
At that point, the John A. Hartford Foundation provided startup funding for the pilot project and awarded OHSU a four year $2.5 million grant to expand the Care Management Plus model into 40 rural and urban clinics. AHRQ provided the funds for the web-based tracking program that was used in the pilot.
During the first year of the program, care management services were pilot tested in seven clinics. Services were provided to 1.7 percent of the 106,766 adult patients seen in age from 65 to 80 plus years. The pilot showed significant improvements in patient outcomes, including fewer complications, deaths, and hospitalizations for diabetes patients. The care manager’s oversight and patient tracking software also increased physician productivity and reduced medical costs, yielding net benefits of about $75,000 per case manager.
The patients in the pilot were referred to a care manager then an individualized care plan was formulated with the patient and his/her caregiver. Periodic visits were made with typically 4.3 encounters per patient made per year. Face-to-face visits amounted to one-third of the encounters, telephone calls were made about 40 percent of the time, and joint meetings with medical team members were made with the patient and with care givers.
Care managers were also able to tap into other resources and settings. As needed, the care manager was able to schedule home appointments with patients, discuss medical issues with physicians and specialists, contact outside agencies and companies to advocate for patients, or arrange for other services to bolster the patient’s care and well-being.
The IT systems were used to facilitate and improve teamwork and communication between primary care providers and specialists to target information needed for each specific patient. The IT tools used did not act as the EHR, but they did augment and work with the existing EHRs. The EHR contained the patient’s record, a longitudinal record, reminders, alerts, and performance reports. The EHR was used as a mechanism so that physicians and care managers were able to communicate with each other on issues relevant to the patient’s care.
The patient worksheet automatically generated by the information system was integrated with the clinic’s scheduling system before each visit. Since the worksheet has pertinent clinical data and alerts for up to five chronic illnesses in a single document, it could be reviewed quickly by providers at the point-of-care and be easily integrated into existing workflows.
Before starting the project, at least 6 physicians were needed to support a care manager and form teams. The IT systems had to be revamped but it is very important to not underestimate IT needs. Also, it has been found that the ability to communicate with the entire team is not often met by the clinic’s present system.
This program is used by PeaceHealth in Oregon and Washington, Healthcare Partners in California, Kaiser Permanente in Oregon, the VA in Oregon and Washington, EXCELth in New Orleans, and several other health systems have adopted this program.
For more information, go to www.innovations.ahrq.gov or email David Dorr, MD at Oregon Health & Science University at radicank@ohsu.edu or call (503) 494-2567.
