Complex Care Management Requires HIT, Analytic Improvements
By Christine Kern, contributing writer
Increased adoption of complex care management can help meet both cost saving and quality improvement goals.
The care of patients with complex medical needs is recognized as one of the dominant factors driving increased U.S. health costs, with approximately 10 to 15 percent of Medicare patients accounting for 65 to 75 percent of all Medicare spending. To respond to these challenges, a number of the nation’s leading healthcare organizations have begun implementing a strategy of complex care management – utilizing coordinated care managers to bring together patients and their family members with the multidisciplinary teams of physicians, nurses, pharmacists, mental health professionals, and others responsible for patient care.
A New England Journal of Medicine article authored by two Massachusetts General Hospital (MGH) physicians presented best practices based on interviews with leaders of 18 complex care management programs, discussed barriers to wider adoption of complex care management, and described potential strategies to surmount those barriers.
"Not only can fully addressing the needs of complex care patients keep them healthier, it also can reduce costs by avoiding emergency department visits and unnecessary hospitalizations," says Clemens Hong, MD, MPH, of the MGH Division of General Medicine, corresponding author of the NEJM article. "In our Perspective piece, we wanted to spell out some of the needs and challenges inherent in establishing complex care management and review potential solutions whether you are working in a large integrated health system in Boston or a small one-doctor practice in rural Arkansas."
The study states, “For successive cohorts of high-risk patients from 2006 through 2012, Massachusetts General Hospital achieved savings of 4 percent, 8 percent, and 19 percent by pursuing a CCM approach. CCM is a nearly universal element of the strategies used by providers accepting financial risk under Medicare's accountable care organization contracts. Even as the momentum builds, however, substantial financial and nonfinancial barriers to more widespread adoption remain.”
The Commonwealth Fund study presents characteristics of successful care management programs, including close collaboration of care managers with all the providers taking care of a complex patient. According to the authors, small, one- and two-physician primary care practices may not have the necessary resources to adequately provide complex care management. In such cases, they suggest, public or private regional organizations can step in to provide the infrastructure for care management that remains closely tied to patients' known providers.
"We have many small practices within the Partners system that often do not have enough complex patients to invest in complex care management resources themselves," according to Hong. "As an integrated delivery system, Partners has the ability to support these practices by providing care managers who may work two or three days a week in several different practices. Not every complex patient needs every service, so sharing resources that are deployed only when and where needed can achieve important economies of scale."
The authors also conclude that complex care is not a one-size-fits-all pattern. There is still a need to research how best to match program design with different practice environments; for training programs and standards; and for advanced analytics and information technology to help identify appropriate patients, provide real-time data and improve workflow. Increased evidence about the savings provided by complex care management should increase its adoption, as the programs not only pay for themselves but also improve health outcomes and reduce fragmentation of patient care.