December 2003

Grant Results

National Program

Chronic Care Initiatives in HMOs

SUMMARY

From 1995 to 1999, researchers at California Pacific Medical Center evaluated a program to improve primary care for senior patients. The program — called the Identification and Early Intervention Program for At-Risk Seniors — sought to identify high-risk non-hospitalized seniors before a crisis arose that would have forced a hospital stay.

Brown & Toland Medical Group — a physicians services organization for over 16,000 physicians in San Francisco and San Mateo counties — had developed the program in 1993.

The project was part of the Robert Wood Johnson Foundation (RWJF) Chronic Care Initiatives in HMOs national program.

Key Findings
In an article in the Journal of the American Geriatrics Society, researchers concluded:

  • "This study provides no statistically significant evidence that social work-oriented case management reduces the use or the cost of health care for high-risk older people. Other potentially favorable effects of this type of case management need to be evaluated, as do the effects of other types of case management."

Funding
RWJF supported this project through a grant of $434,255.

 See Grant Detail & Contact Information
 Back to the Table of Contents


THE PROBLEM

Many hospital admissions of elderly patients result from preventable factors. In 1993, Brown & Toland developed the Identification and Early Intervention Program for At-Risk Seniors to improve primary care for senior patients by identifying high-risk nonhospitalized seniors before a medical crisis arose that would force a hospital stay.

Referrals to the program came from physicians, hospital case managers and other medical personnel, as well as from staff at Seniors At Home (the community-based social service agency with which Brown & Toland contracted) trained as geriatric resource persons (GRPs). GRPs identified older patients visiting the office who might benefit from case management by Seniors at Home. Referrals also came through an intake-screening questionnaire that incorporated standard risk-measurement tools.

 Back to the Table of Contents


THE PROJECT

Researchers planned to conduct the evaluation of the Identification and Early Intervention program in an independent practice association (i.e., an HMO model in which the HMO contracts with a physician organization that in turn contracts with individual physicians) in three phases: a pilot test, a larger study and field testing in physicians' offices. Brown & Toland and the California Pacific Medical Center provided in-kind support for staffing, program incidentals and case management.

In Phase I, conducted in 1995, researchers reviewed data on 1,500 senior HMO members identified as at risk and compared their inpatient and outpatient use to the overall HMO senior population. The findings showed the at-risk group to have higher service use.

In Phase II, which also began in 1995, researchers randomly selected 6,409 elderly HMO patients and divided them into a treatment group (3,480 patients) and a control group (2,929 patients) that did not receive identification and early intervention. Thirty-three primary care physician offices, 65 physicians and 48 GRPs provided the care. Researchers outlined the following hypotheses to be tested over the three-year grant period:

  • Treatment group patients will have greater amounts of case management services, home health visits and physician office visits than the control group.
  • Treatment patients will have fewer emergency room visits, skilled nursing days and hospital days than the control group.
  • Treatment group patients, when considered as a total group (i.e., including those patients who were not identified as high risk), will have lower overall per-member per-month costs than the control group.
  • Treatment group patients, when considering only those needing the Identification and Early Intervention program (i.e., identified as high risk), will have overall lower per-member per-month cost than comparable risk groups within the control sample.

Due to financial constraints, Brown & Toland terminated the Identification and Early Intervention program before Phase III could be conducted.

In 1999, following a competition honoring excellent managed care programs for seniors, the American Society of Aging awarded Seniors at Home and Brown & Toland the "Managed Care and Aging: Recognizing Innovation and Quality" award.

 Back to the Table of Contents


FINDINGS

In an article in the Journal of the American Geriatrics Society, researchers noted, "The results suggest that the IEI [Identification and Early Intervention] program was cost-neutral, but we should interpret these results carefully."

  • "Within the experimental [treatment] group, recipients of case management were older, markedly sicker, more depressed, more anxious, more disabled, more medicated and more likely to have lost weight and used health services in the last year than the nonrecipients."
  • Costs for the treatment group were slightly lower ($3,148) than for the control group ($3,277).
  • The treatment group received .09 months of case management at an average annual cost of $9.80 per person while the control group received .02 months of management with an average annual cost of $1.56.
  • Home health visits in the treatment group averaged 1.14 visits per person while the control group had .95 visits, with associated annual average cost of $85.03 and $66.44, respectively.
  • Physician visits were nearly the same for both groups, with the treatment group seeing the primary care physicians and specialists slightly less, on average, than the control group — 12.99 times, compared to 13.11 times for the control group. Associated physician costs were $975.13 per year for the treatment group and $1,012.11 per year for the control group.
  • Treatment patients had fewer skilled nursing days and hospital days than the control group. Treatment patients had .92 skilled nursing days annually compared to 1.2 for the control group. Treatment patients also had 1.06 hospital days annually compared to 1.14 for the control group. However, emergency room visits for the treatment and control groups was the same, at .49 visits annually.

The researchers concluded, "This study provides no statistically significant evidence that social work-oriented case management reduces the use or the cost of health care for high-risk older people. Other potentially favorable effects of this type of case management need to be evaluated, as do the effects of other types of case management…. A new taxonomy for classifying different models of case management will be essential in the continuing investigation of the effects of case management on the health and cost of health care of older people."

Limitations

Analytical constraints did not allow for the comparison of costs for the most relevant subgroups, i.e., only those given the Identification and Early Intervention program and a like control subgroup. Other constraints, including those involving effects on data of patient deaths or disenrollments, limit the generalizability of this study's analysis.

Communications

Researchers published two articles on the Identification and Early Intervention program, including one in the peer-reviewed Journal of the American Geriatrics Society. (See the Bibliography for details.) They also made four presentations to professional groups.

 Back to the Table of Contents


AFTER THE GRANT

In October 1998, California HealthCare Foundation awarded Seniors at Home, in collaboration with Brown & Toland and the division of geriatrics at the University of California in San Francisco, a three-year grant. Researchers sought to determine the effects of the intervention on the medical care costs and health outcomes of the program in a Medicare at-risk program. According to the principal investigator of this evaluation, however, low enrollment levels prevented them from obtaining conclusive results.

 Back to the Table of Contents


GRANT DETAILS & CONTACT INFORMATION

Project

Identification and Early Intervention Program for At-Risk Seniors

Grantee

California Pacific Medical Center Foundation (San Francisco,  CA)

  • Amount: $ 434,255
    Dates: May 1995 to May 1999
    ID#:  027026

Contact

Project Director: Richard J. Moore, M.D.
(415) 387-8800
rjmoore@mindspring.com

 Back to the Table of Contents


BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Boult C, Rassen J, Rassen A, Moore RJ and Robison S. "The Effect of Case Management on the Costs of Health Care for Enrollees in Medicare Plus Choice Plans: A Randomized Trial." Journal of the American Geriatrics Society, 48(8): 996–1001, 2000. Abstract available online.

Gutman J. "Initial Results Show IPA's Disease Management Program Slashed Costs." Disease Management News, 1(22): 8, 1996.

 Back to the Table of Contents


Report prepared by: Robert Crum
Reviewed by: James Wood
Reviewed by: Molly McKaughan
Program Officer: Rosemary Gibson
Program Officer: Pamela S. Dickson

Most Requested