Case Management for Health Care Superutilizers

Overseen By Eileen Birmingham

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: UnitedHealthcare

Must not be taking: Infertility medications

Disqualifiers: Pregnancy, Dementia, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: Unknown

Duration: 24 months

592023 Participants Needed

Trial Summary

What is the purpose of this trial?

The Standard Care Coordination (SCC) solution integrates aspects of case management \& care coordination \& was designed by UnitedHealth Group for high-cost, complex, at-risk consumers to facilitate health care access and decisions that can have a dramatic impact on the quality and affordability of the consumer's health care. Currently members only receive the SCC if they are: 1) identified as high risk for readmission upon discharge from the hospital, 2) are self-referred, or 3) are directly referred to the program by their physician. The current quality improvement study was designed as a randomized controlled trial to determine if the expansion of the SCC program to commercially insured members identified via a proprietary administrative algorithms as being at high risk would significantly impact rates of acute inpatient admissions.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It is best to discuss this with the trial coordinators or your doctor.

What data supports the effectiveness of the treatment Community Health Worker Case Management and similar approaches?

Research shows that case management, which involves coordinating a patient's healthcare services, can improve treatment adherence and patient outcomes, especially for those with complex health issues. This approach has been effective in improving care coordination and quality of life for patients with conditions like cancer and musculoskeletal injuries. ^{1 2 3 4 5}

Is case management generally safe for humans?

Case management, which involves coordinating healthcare services, is generally considered safe and focuses on improving patient safety by using decision support tools and safety protocols. It is used to enhance patient outcomes and reduce hospital readmissions, indicating a focus on safety in its application. ^{5 6 7 8 9}

How is the treatment 'Case Management for Health Care Superutilizers' different from other treatments?

This treatment is unique because it involves a comprehensive approach using community health workers and nurses to coordinate care, focusing on prevention, continuity, and cost reduction, which is particularly beneficial for high-risk patients who frequently use healthcare services. ^{10 11 12 13 14}

Research Team

Anthony V Pirrello, MS

Principal Investigator

UnitedHealthcare

Eligibility Criteria

This trial is for UnitedHealthcare commercial members over 18 years old, in any state, who are at high risk of frequent hospital visits as determined by a special algorithm. It's not for pregnant women, those with 'do not contact' status, on infertility treatment or part of certain health plans like ACOs or legacy UHC groups.

Inclusion Criteria

I am over 18, have UnitedHealthcare, and am considered at high risk for frequent healthcare needs.

Exclusion Criteria

Members in legacy UHC ASO groups

Members in legacy Oxford health plan

Members in legacy PacifiCare

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants receive standard care coordination and disease management, with some receiving additional case management

24 months

Follow-up

Participants are monitored for safety and effectiveness after treatment

24 months

Long-term Monitoring

Participants are monitored for various health outcomes such as emergency room visits, diabetes-related complications, and adherence to care processes

48 months

Treatment Details

Interventions

• Community Health Worker Case Management
• RN case management
• RN Standard care coordination and disease management

Trial Overview The study tests if expanding Standard Care Coordination (SCC), which includes case management and care coordination by RNs and community health workers, to high-risk insured members can reduce hospital admissions. Participants are randomly chosen to receive SCC.

Participant Groups

Group I: Treatment 2 Experimental Treatment 2 Interventions

RN Standard care coordination and disease management + Community Health Worker Case Management

Group II: Treatment 1 Experimental Treatment 2 Interventions

RN Standard care coordination and disease management + RN Case Management

Group III: Control Experimental Treatment 1 Intervention

RN Standard care coordination and disease management

Community Health Worker Case Management is already approved in United States for the following indications:

Approved in United States as Standard Care Coordination for:

• High-risk patient management
• Complex care coordination
• Prevention of acute inpatient admissions

Who Is Running the Clinical Trial?

UnitedHealthcare

Lead Sponsor

Trials

5

Recruited

594,000+

University of California, Los Angeles

Collaborator

Trials

1,594

Recruited

10,430,000+

Findings from Research

Improving treatment adherence is crucial for reducing health issues and costs, especially among low-income and minority patients, as it involves complex interactions between patients, providers, and health systems.

The paper outlines five key elements for a best practice case management approach, supported by theory and evidence, and highlights the SAFe program, which has successfully enhanced adherence in patients with abnormal cancer screenings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Best practice case management for improved medical adherence. Vourlekis, B., Ell, K.[2007]

The study demonstrated that having an embedded nurse case manager in primary care medical homes led to significant reductions in healthcare costs and improved quality of care, with four out of five sites showing notable enhancements in service delivery.

Staff and case managers reported high satisfaction with the embedded case manager role, indicating that this approach can enhance patient outcomes and operational efficiencies in healthcare settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Collaborating for care: initial experience of embedded case managers across five medical homes. Treadwell, J., Giardino, A.[2014]

General practitioners (GPs) expressed skepticism about the effectiveness of nurse case managers, particularly community matrons, in reducing hospital admissions, indicating concerns about their ability to improve patient outcomes.

The introduction of community matrons may disrupt established working relationships between nurses and GPs, suggesting that changes in nursing roles should be implemented carefully to avoid negative perceptions and resistance from healthcare professionals.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Nurse case management and general practice: implications for GP consortia. Iliffe, S., Drennan, V., Manthorpe, J., et al.[2021]

A study involving 244 breast cancer patients (126 in a case management program and 118 receiving standard treatment) found that the case management program did not significantly improve health-related quality of life or reduce psychological distress compared to standard treatment.

Both groups showed improvements over time, but the case management model did not provide additional benefits, suggesting that the existing standard care may already be effective or that the case management approach needs further refinement.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effectiveness of case management as a cross-sectoral healthcare provision for women with breast cancer. Bleich, C., Büscher, C., Melchior, H., et al.[2018]

Case management effectively coordinates health care services for individuals, ensuring quality care while controlling costs, as demonstrated by the structured approach used by occupational health nurses.

The Case Management Activity Checklist, tested on 61 firefighters with musculoskeletal injuries, provides a systematic method for documenting case management activities and measuring outcomes, enhancing communication and treatment planning.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A case management tool for occupational health nurses: development, testing, and application. Mannon, JA., Conrad, KM., Blue, CL., et al.[2006]

Case management is an effective approach for healthcare professionals to optimize resource use and maintain quality care, leading to significant reductions in patient length of stay and cost savings for healthcare organizations.

Successful case management relies on a collaborative team structure, including case managers and interdisciplinary teams, to coordinate care and ensure that patients' diverse needs are met, ultimately enhancing patient satisfaction and hospital reputation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

An introduction to case management. Kurec, A.[2019]

Hospital-based case managers play a crucial role in reducing preventable readmissions by directly interacting with patients to identify factors leading to their return, emphasizing the need for comprehensive discharge planning.

Collaboration with community-based providers and the involvement of pharmacists in discharge planning are essential strategies for improving patient outcomes and ensuring compliance with Medicare discharge planning standards.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Preventing readmissions through comprehensive discharge planning. Hunter, T., Nelson, JR., Birmingham, J.[2022]

A 2003 study by URAC highlighted that patient safety is often addressed indirectly by medical management companies through broader quality management programs, indicating a need for more direct safety measures.

The study emphasized the importance of decision support tools and adapted assessment protocols in case management to systematically identify and address safety concerns, suggesting that case managers play a crucial role in enhancing patient safety within the healthcare system.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Patient safety systems for case management. Greenberg, L.[2019]

The collaborative nursing/social worker case management intervention led to a significant 48% reduction in emergency department visits among a low-income uninsured population, resulting in an estimated charge avoidance of $1,446,280.

While physical health status improved significantly due to the intervention, mental health status and health locus of control scores showed only minimal changes, suggesting that while access to care improved, further support may be needed for mental health outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Impact of a collaborative community case management program on a low-income uninsured population in Sedgwick County, KS. Wetta-Hall, R.[2018]

Nursing case management is an emerging approach in healthcare that focuses on coordinating care across various stages, including prevention, acute care, rehabilitation, and hospice, to improve patient outcomes.

Effective nurse case managers should have at least a bachelor's degree, possess strong clinical skills, and be knowledgeable about the healthcare system and finances, using various tools to enhance clinical and economic outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The ABCs of case management. A review of the basics. Strassner, LF.[2005]

Case management is recognized as a valuable approach to enhance service delivery in both health and mental health systems, but its application differs significantly between the two fields.

There is a growing conflict in mental health services between the goals of cost control and ensuring continuity of care, highlighting the need for strategies to balance these competing priorities.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Continuity of care and the control of costs: can case management assure both? Baker, F., Vischi, T.[2019]

Case management is an effective strategy for reorganizing healthcare delivery to improve quality while lowering costs.

Successful implementation of case management requires careful planning and execution to ensure that healthcare services are delivered efficiently.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Case management: implementing the vision. Stiller, AL., Brown, HN.[2005]

Nurse case management is an effective strategy for coordinating healthcare services for frail elderly individuals living in the community, focusing on engagement with clients and their families.

This approach emphasizes prevention and continuity of care, with nurse case managers acting as facilitators among hospitals, communities, and caregivers to improve health outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Case management of the frail elderly in the community. Guttman, R.[2019]

Nursing case management significantly improves access to care in community settings through five key components, including bridging health systems and providing tailored health promotion.

Challenges such as regulatory ambiguity, high caseloads, and insufficient training for nurses need to be addressed to enhance the effectiveness of case management in these settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Implementation of nursing case management to improve community access to care: A scoping review. Putra, ADM., Sandhi, A.[2023]

References

1. United States pubmed.ncbi.nlm.nih.gov

Best practice case management for improved medical adherence. [2007]

2. United States pubmed.ncbi.nlm.nih.gov

Collaborating for care: initial experience of embedded case managers across five medical homes. [2014]

3. England pubmed.ncbi.nlm.nih.gov

Nurse case management and general practice: implications for GP consortia. [2021]

4. England pubmed.ncbi.nlm.nih.gov

Effectiveness of case management as a cross-sectoral healthcare provision for women with breast cancer. [2018]

5. United States pubmed.ncbi.nlm.nih.gov

A case management tool for occupational health nurses: development, testing, and application. [2006]

6. United States pubmed.ncbi.nlm.nih.gov

An introduction to case management. [2019]

7. United States pubmed.ncbi.nlm.nih.gov

Preventing readmissions through comprehensive discharge planning. [2022]

8. United States pubmed.ncbi.nlm.nih.gov

Patient safety systems for case management. [2019]

9. United States pubmed.ncbi.nlm.nih.gov

Impact of a collaborative community case management program on a low-income uninsured population in Sedgwick County, KS. [2018]

10. United States pubmed.ncbi.nlm.nih.gov

The ABCs of case management. A review of the basics. [2005]

11. England pubmed.ncbi.nlm.nih.gov

Continuity of care and the control of costs: can case management assure both? [2019]

12. United States pubmed.ncbi.nlm.nih.gov

Case management: implementing the vision. [2005]

13. United States pubmed.ncbi.nlm.nih.gov

Case management of the frail elderly in the community. [2019]

14. Indonesia pubmed.ncbi.nlm.nih.gov

Implementation of nursing case management to improve community access to care: A scoping review. [2023]