The value of targeted case management during transitional care.

Abstract

AFTER ESTABLISHING A LEGACY OF SUCCESS THROUGH the ascendancy of acute care and biomedical interventions during the past half century, medicine is entering an era of chronic disease management. As the United States now grapples with the burgeoning needs of an aging society and upwardly spiralling health care costs, new strategies for organizing health care are essential. In this issue of THE JOURNAL, Naylor and colleagues present findings from a randomized trial that demonstrates the effectiveness of 1 such strategy. Within any population, a small subset of patients incurs most of the episodes of serious illness and generates a large fraction of total medical costs. Also, patients who are hospitalized once are more likely to have readmissions, although it is difficult to predict which specific patients will be involved. These concepts are particularly germane in geriatrics because the higher prevalence of serious chronic illness drives more utilization of all health services. Naylor et al have convincingly shown that focused, shortterm case management around the time of hospital discharge can dramatically reduce subsequent readmissions and total hospital days for a selected group of elderly patients. One of the main principles tested in their study is the value of continuous care during transitions between settings of care and times of medical instability. Care continuity is important, and discontinuity is a weakness in US health care delivery, one that is perpetuated by funding mechanisms that do not align the interests of health care personnel in various settings. The effects of payer mix also must be considered in interpreting the findings of this study. The main outcome of the intervention was a reduction in readmissions. This result probably is better for patients, and certainly is better for the Medicare budget, but the strategy might appeal less to a hospital manager competing in an environment dominated by diagnostic related groups in which readmissions generate new revenue. Conversely, when financial risk increases, as in some Medicare health maintenance organization contracts, or the underfunded care of the poor at public hospitals and many academic health centers, administrators might readily espouse a case management model with a similar focus. As the authors note, their findings also suggest that effective case management does not have to focus on 1 particular disease. Previous work has shown value in selected disease-specific case management strategies, andsuchprogramshaveproliferated. However, geriatric care is inherently filled with the crossing currents of comorbid illnesses and many patient care situations do not lend themselves as easily to a disease-specific approach. Naylor et al also found that the effect of a 1-month intervention appeared to persist through the 6-month study period. The authors speculate that the intervention improved the ability of high-risk elders to cope with medical problems and disabilities. If so, this is encouraging, and is consistent with findings in another study that used nurse practitioners in a public health, preventive care model and reduced long-term nursing home stays for elderly patients. Empowering patients and caregivers is a popular and prudent strategy for the coming era of constrained medical resources. Several caveats are needed regarding the study by Naylor et al. First, it is unclear whether control group patients had access to a system of continuous care; if not, this aspect could limit generalizability. Also, because the study was confined to 2 urban hospitals in a single market, additional studies are needed to confirm the applicability of the findings elsewhere. Second, mental status test scores suggest that this study population was cognitively intact; whether a similar intervention would be as effective in patients with cognitive impairment is unknown. Several factors may have enhanced the effectiveness of the intervention nurses. The total number of nurse home visits was similar in the 2 groups when visits by intervention advanced practice nurses and home health agency nurses were combined. Yet, control patients had more readmissions. Naylor et al attributed this difference to the broader clinical reach of the gerontologic advanced practice nurses. This may well be a factor and confirms my 12 years’ experience working with nurse practitioners in a hospital-based medical home care practice. However, it is also possible that the involvement of the advanced practice nurses during both inpatient and outpatient phases of care, and probably their easier access to other medical care managers (eg, physicians) during the transition, might also have enhanced the intervention nurses’ impact.