Abstract
BackgroundCare management programmes are an effective approach to care for high risk patients with complex care needs resulting from multiple co-occurring medical and non-medical conditions. These patients are likely to be hospitalized for a potentially "avoidable" cause. Nurse-led care management programmes for high risk elderly patients showed promising results. Care management programmes based on health care assistants (HCAs) targeting adult patients with a high risk of hospitalisation may be an innovative approach to deliver cost-efficient intensified care to patients most in need.Methods/DesignPraCMan is a cluster randomized controlled trial with primary care practices as unit of randomisation. The study evaluates a complex primary care practice-based care management of patients at high risk for future hospitalizations. Eligible patients either suffer from type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic heart failure or any combination. Patients with a high likelihood of hospitalization within the following 12 months (based on insurance data) will be included in the trial.During 12 months of intervention patients of the care management group receive comprehensive assessment of medical and non-medical needs and resources as well as regular structured monitoring of symptoms. Assessment and monitoring will be performed by trained HCAs from the participating practices. Additionally, patients will receive written information, symptom diaries, action plans and a medication plan to improve self-management capabilities. This intervention is addition to usual care.Patients from the control group receive usual care.Primary outcome is the number of all-cause hospitalizations at 12 months follow-up, assessed by insurance claims data. Secondary outcomes are health-related quality of life (SF12, EQ5D), quality of chronic illness care (PACIC), health care utilisation and costs, medication adherence (MARS), depression status and severity (PHQ-9), self-management capabilities and clinical parameters. Data collection will be performed at baseline, 12 and 24 months (12 months post-intervention).DiscussionPractice-based care management for high risk individuals involving trained HCAs appears to be a promising approach to face the needs of an aging population with increasing care demands.Trial registrationCurrent Controlled Trials ISRCTN56104508
Highlights
Care management programmes are an effective approach to care for high risk patients with complex care needs resulting from multiple co-occurring medical and non-medical conditions
Practice-based care management for high risk individuals involving trained health care assistants (HCAs) appears to be a promising approach to face the needs of an aging population with increasing care demands
We developed a primary care practice-based care management intervention for patients suffering from any of these index conditions with a high likelihood of hospitalization as predicted by a statistical model [18]
Summary
Care management programmes are an effective approach to care for high risk patients with complex care needs resulting from multiple co-occurring medical and non-medical conditions These patients are likely to be hospitalized for a potentially “avoidable” cause. Medical care for patients with multiple chronic conditions is often fragmented by poor coordination between different healthcare providers [5] These patients are more likely to be hospitalised for a potentially ‘avoidable’ cause (e.g., unmanaged exacerbation, intermittent infection or falls, imperfect transitional care), leading to suboptimal health outcomes [6] and substantial healthcare costs [7]. Different suggestions are available to take up the challenge by re-organising the delivery of chronic illness care [10,11] Based on these concepts, care management interventions have been developed and evaluated focusing on patients with multiple chronic conditions. Care management interventions have shown to be effective and efficient if they focus on patients with high risk of healthcare utilization [9,13]
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