Comprehensive Case Management Case Study

JOURNAL OF PALLIATIVE MEDICINE Volume 12, Number 9, 2009 ª Mary Ann Liebert, Inc. DOI: 10.1089=jpm.2009.0089

Original Article

A Comprehensive Case Management Program To Improve Palliative Care
1 1 Claire M. Spettell, Ph.D., Wayne S. Rawlins, M.D., M.B.A.,2 Randall Krakauer, M.D.,3 Joaquim Fernandes, M.S., 2 2 2 Mary E.S. Breton, B.S., J.D., Wayne Gowdy, B.S., Sharon Brodeur, R.N., B.S., M.P.A., Maureen MacCoy, B.S.N., M.B.A.,2 and Troyen A. Brennan, M.D., M.P.H.4

Abstract

Objective: The objective of this study was to evaluate the impact of comprehensive case management (CM) and expanded insurance benefits on use of hospice and acute health care services among enrollees in a national health plan. Study Design: Retrospective cohort
The number of days in hospice was not available from this source. The flag indicating hospice in the health plan utilization management system was not available for the Medicare control group, thus, the hospice use rate was not calculated for this group. Secondary outcome measures The acute care utilization measures were calculated from health plan claims data, and included the proportion of members with acute care hospital admissions, the rate of acute hospital inpatient days per 1000 members, proportion of members with an intensive care unit (ICU) stay during an acute hospitalization, proportion of members with emergency visits, the rate of emergency department visits per 1000 members, and rate of primary care and specialist vists per member. No directional hypotheses were made for these measures. Measures expressed as days per 1000 members were calculated as the number of days divided by the number of members in the CM Group multiplied by 1000. Statistical analysis Generalized linear models were used to compare outcome variables between groups with a subject effect variable to adjust for the paired nature of the data. McNemar’s test was used for comparing proportions. A generalized linear model assuming a two parameter Poisson probability distribution was employed for comparing rates represented as counts per thousand. The two-parameter Poisson was chosen for the response
Medicare case management Lung cancer Gastrointestinal cancer Congestive heart failure Neoplasms—Other COPD Colorectal cancer Breast cancer Prostate cancer Chronic renal failure Diabetes mellitus Respiratory failure Cerebrovascular disease Hematologic cancer Pneumonia Hypertension 19.5% 9.6% 6.7% 6.5% 6.0% 4.9% 3.4% 3.1% 2.9% 2.9% 2.9% 2.2% 2.2% 1.6% 1.6%

15.9 days to 28.6 days ( p < 0.0001) for the CM group. The rate of use of hospice in the Medicare CM Group was 62.9%. The percentages of members with an acute inpatient stay after program enrollment were reduced for the Enhanced Benefits CM Group (16.8% versus 40.3%, p < 0.0001), CM group (22.7% versus 42.9%, p < 0.0001), and Medicare CM group (30.0% versus 88.4%, p < 0.0001) compared to their respective control groups. The number of acute inpatient days was reduced for the Enhanced Benefits CM group (1549 versus 3986 days per thousand members, p < 0.0001),