Sick To Death > Chapter 3 > Coordinating and Managing Care
Patients with serious chronic illness often see many specialists and other health-care professionals in a range of settings. Coordination of care for these patients among providers and across provider sites is important to avoid complications (such as monitoring drug interactions or transfer of patient-care plan across settings), but health-care systems rarely provide this service. The fragmentation and disorganization of the fee-forservice health-care system leads to frustration, inappropriate services, the potential for medical error and threats to patients' safety, and substantial human and financial costs. Many organizations have attempted to coordinate medical, social, and family resources for these patients, under the premise that doing so will improve their quality of life while reducing medical expenses (Boult, Kane, and Brown 2000). The care system has become too complex for its users, and the usual encounter between physician and patient regularly overlooks many services that would prevent complications or suffering.
For example, educating patients and families to provide self-care is rarely part of physicians' office practice, but it regularly yields better outcomes and lower costs (Lorig et al. 1999). Teaching self-care in classes seems to be more effective than one-on-one education, and the classes also offer socialization and support; but Medicare will not pay for services provided to multiple beneficiaries at the same time (thus, no coverage for classes). Programs that efficiently connect families and patients with needed services often increase costs, since people benefit from more services, but they more reliably meet patients' needs and usually allow them to function better, with reduced symptoms, fewer exacerbations, and otherwise better outcomes.
Geriatric evaluation and management combine evaluation of an older person's medical, psychosocial, and functional capabilities over several months of treatment and follow-up conducted by an interdisciplinary team (at least a doctor, nurse, and social worker) using standardized assessment and treatment protocols. A recent randomized trial showed that geriatric evaluation and management preserved out-patients' functional ability, decreased depressive symptoms, improved satisfaction, and reduced the burden felt by family caregivers, at a cost of about $1,250 per person (Province et al. 1995).
There are a few distinctions between care coordination, case management, and disease management. For the most part, case management uses a medical model to focus on a patient's health care and health status and to coordinate a list of covered services, while care coordination focuses on the patient's need for an array of social services in his or her own environment (such as housing needs, income, and social supports) and coordinates a full range of medical and social support services, including those offered by others, in the community, outside the program (Rosenbach and Young 2000).
Whereas case management tends to serve a smaller group of complex, medically or socially vulnerable "high-risk" patients with highly individualized plans of care, disease management tends to serve a larger group of less individualized patients whose main problem is a single chronic disease. Disease management usually targets populations who are costly and have high but modifiable risks of adverse medical outcomes, including patients with chronic heart failure, diabetes, asthma, chronic obstructive pulmonary disease, or end-stage renal disease. These patients generally have similar primary needs, and the program can take a more standardized approach (Chen et al. 2000; Kane and Kane 2001).
Disease management and care-coordination programs also target different populations and must target them carefully. A program that is too inclusive may be unable to provide the level of services necessary to improve patient outcomes or achieve savings equal to the costs of the program. Similarly, a program that targets too narrowly may miss many appropriate patients and not achieve savings equal to the costs of the program. The literature on chronic-care management interventions has shown that the ability of a program to identify those individuals who would benefit from the interventions is crucial to its success (Wilkinson 1996; Medicare Payment Advisory Commission 2003).
Disease management programs work reasonably well with people who can go to the doctor, use the phone, follow instructions, and have only one major illness; but most of those programs have no experience with a person who has multiple illnesses, hearing and mobility deficits, and other social problems. Care coordination and case management can orchestrate existing services, but they cannot engender new ones; these approaches run into gaps when the needed services simply aren't available. As people become more ill and fragile, for example, having medical services at home can be essential. The care coordinator can identify the problem but cannot fill the need. Thus, no program of care coordination, case management, or disease management is reliably able to serve the sickest patients well. An optimal approach would manage diseases by coordinating services and by generating those not now readily available outside hospice, such as in-home physician care.
Kaiser Permanente's medical center in Bellflower, California, has developed a model program (mentioned earlier) that blends features of these models for patients with heart failure or emphysema (http://www.growthhouse.org/palliative; Lynn, Nolan, et al. 2002). Since 1995, the program has relied on a nurse practitioner to train patients and families on monitoring symptoms at home to reduce exacerbations and unnecessary hospitalizations. Ties to the Kaiser home health and hospice program have improved care for patients who are nearing the end of life. The program has decreased hospitalizations and increased hospice enrollment for patients with advanced heart and lung disease, patients who are not typically referred to hospice (National Coalition for Health Care and Institute for Healthcare Improvement 2000).
Various studies have indicated that caregivers and care-management clients experience a higher quality of life, have better mental functioning, and enjoy increased social activities. While case management often produces beneficial outcomes for patients, the evidence on the net cost of these programs is mixed (Wilkinson 1996; Boult, Kane, and Brown 2000). Many programs increase the cost of medical care. Case management usually increases spending on community services too. Even so, reduced use of nursing homes may eventually yield net savings, though care-management enrollees are not likely to move to nursing homes soon after enrollment. For these more moderately frail clients, costs are unlikely to be reduced (Wilkinson 1996). Medicare has offered a few demonstration projects to test disease management and the benefit structure that would support it (Crippen 2002; Berenson and Horvath 2003), and the 2003 Medicare reform statute provides for large-scale implementation and evaluation (Medicare Prescription Drug, Improvement, and Modernization Act 2003).