Improving Quality and Reducing Costs in Highest Health Care Utilizers of PCMHs

In the United States, 10% of patients covered by public insurance account for 70% of health expenditures and patients with chronic medical conditions account for over 80% of all health care spending. In the Military Health System (MHS) where patients are comparatively younger and healthier, 25% of the population have a chronic medical condition and account for nearly 50% of the health care costs. Care Management (CM), distinct from case management or disease management, has emerged as a successful targeted intervention led by a specially trained Nurse Care Manager that improves quality and reduces costs among the highest health care utilizers. Additionally, mathematical models have been developed that can predict which high utilizer patients are at highest risk for future high health care utilization; one model can predict which patients are most likely to benefit from CM. This study aims to pilot the deployment of an evidence-based (EB) CM model focused on patients who are selected by a well validated EB predictive model to be at highest risk for high health care resources utilization and also who are most likely to benefit from CM in Naval Medical Center San Diego Patient-Centered Medical Homes (PCMH). The study will explore the feasibility of the deployment of this CM model within the MHS and the subsequent outcomes on the quality of care and health care utilization and costs. This study is a prospective randomized controlled pilot of CM versus usual care (UC) in PCMHs with 21-months of follow-up. 360 subjects (60 CM vs. 60 UC for 3 patient age groups 18-44yrs; 45-64yrs; and 65yrs and above) will be randomized. Three Nurse Care Managers will be trained in the Guided Care CM model which includes home assessments, EB care guides/action plans, monthly monitoring and coaching, coordination of care, smooth transitions of care, self-management, caregiver education-support, connection to community and military resources, and in-hospital visits. Analyses will be performed at baseline, 15 and 24 months. Measured outcomes will include patient reported quality of care and utilization measures such as clinic and ER visits, hospital admissions, hospital days, skilled nursing facility days, home health days, and total costs as measures of the impact on PCMHs.     

Relevance:  Demonstration of feasibility, improvements in quality and/or utilization and cost-benefit in this pilot has the potential to influence Nursing practices and expand the CM model to a larger population of patients. If implemented in military health systems, the CM model has the potential to improve patient outcomes and reduce costs in the care of Uniformed Service Members and their families with complex medical needs.