Case management is not the be-all and end-all of ‘integrated care’

20 Jul

by Jonathan Stokes, PhD student in Multimorbidity theme

Jonny Stokes_July15 blog on paper

The major health burden in any rich country (and increasingly poorer countries as well) is long-term conditions, e.g. asthma, diabetes, heart disease.

As people live longer, they tend to accumulate multiple long-term conditions over their lifetime, known as multimorbidity. These patients often require care from many parts of the health and social care system, use multiple medications, and their care is generally more complex and expensive to manage. These pressures have been further exacerbated by the 2008 economic crisis and subsequent austerity measures.

Better ‘integrated care’ is a common response from policy-makers, to achieve better outcomes for patients, and in a more cost-effective manner. Integrated care is a complicated concept, and it can be delivered at multiple levels of the health system, in the ‘background’ (e.g. integrated health records, pooled funding), or at the point of ‘service delivery’ (at the point of contact with the patient).

Case management for ‘at risk’ patients in primary care is an extremely popular way of ‘integrating’ service delivery. It involves identifying patients at increased risk of emergency admissions to hospital, and assigning them a specific case manager or case management team to tailor and co-ordinate their care (with an individual assessment, care plan, and regular review).

In the NHS, case management of the top 2% of highest risk patients is part of the current GP contract. Under the ‘Unplanned admissions directed enhanced services (DES)’, practices receive extra payments for signing up to these services.

Despite probably being the main form of integrated care being implemented in the NHS and around the world (looking at the NHS specifically, we previously found a clear dominance of case management being implemented as the core aspect of ‘integrated care’ in Clinical Commissioning Groups), with the aim of cost-saving and achieving better outcomes for patients, the evidence for this intervention is unclear.

We conducted a systematic review of the evidence generated to date. We used a statistical technique, called ‘meta-analysis’, to put together the findings of all of the studies we found. This technique increases statistical power (increasing precision and our confidence in the findings), and provides an assessment of all the high quality evidence available globally. For that reason, it’s often referred to as the gold-standard form of evidence in medicine.

We looked at effectiveness across a number of outcomes: health (patients’ assessment of their health, as well as mortality), costs and cost-effectiveness (total costs of care, as well as the use of specific services such as GPs, social workers, and hospitals care), and patient satisfaction.

Exploring data across 36 studies, we found that case management of at-risk patients in primary care showed no significant effect on most of the outcomes we looked at. The exceptions were self-assessed health status (which may improve slightly in the short-term, but with few long term benefits), and patient satisfaction (which improved a small amount in both the short and longer term).

We found little evidence of effectiveness of a very popular method of delivering ‘integrated care’.

Managing those high-risk patients is also important, and while the intervention analysed showed limited benefit, there was no harm shown. Therefore, we also tried to pick out some key learning opportunities for policy-makers to try and improve the interventions delivered in the meantime (for example, we found there may be slight benefits of using a multidisciplinary team to case manage; slightly more effect in a country with low initial strength of primary care; and there may be benefits when a social worker is involved).

Policy-makers may need to broaden their thinking about methods to improve care for those with multiple conditions. As others have pointed out, targeting only the highest risk patients puts limits on what can be achieved.

As enthusiasm for integrated care grows through the Five Year Forward View and the Vanguard programme, methods of achieving service improvement at scale need urgent evaluation.

With limited effectiveness shown for the main aims of the case management intervention, particularly no effect in reducing hospital admissions and total cost of care, for policy-makers to incentivise practices to implement case management appears counter-productive to relieving system pressures.

The full article can be found on PLoS ONE, titled: ‘Effectiveness of case management for ‘at risk’ patients in primary care: A systematic review and meta-analysis’ (DOI: 10.1371/journal.pone.0132340).

2 Responses to “Case management is not the be-all and end-all of ‘integrated care’”

  1. dukejonny July 20, 2015 at 2:53 pm #

    Reblogged this on dukejonny.

Trackbacks/Pingbacks

  1. The ‘triple aim’: a reality check | GM PSTRC - January 27, 2017

    […] to improve health and satisfaction of patients, while reducing costs. With the move towards ‘integrated care’, policymakers argue that integration can improve all triple-aim outcomes […]

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