Research ArticleSystematic Review

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review

Catherine Hudon, Maud-Christine Chouinard, Pierre Pluye, Reem El Sherif, Paula Louise Bush, Benoît Rihoux, Marie-Eve Poitras, Mireille Lambert, Hervé Tchala Vignon Zomahoun and France Légaré
The Annals of Family Medicine September 2019, 17 (5) 448-458; DOI: https://doi.org/10.1370/afm.2419

Article Figures & Data

Tables

  • Table 1

    Description of Included Studies

    First Author, Year, (Country)DesignSettingPopulation (CM Intervention Inclusion Criteria)NMain Characteristics of the InterventionOutcomMethodological Quality Score, %
    Adam et al,40 2010 (USA)Nonrandomized trialPrimary care clinic>8 clinic visits/year with multiple comorbidities (physical, psychiatric and psychosocial issues)I: 12
    C: 8    		Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include referral to mental health services, review of medication, and care coordination. The PCP presented the care plan to the patient and amended it if needed.↓ Clinic visits
    ↑ Well-being
    ↑ Patient satisfaction ↑ Quality of care
    ↑ No show or cancelled appointments
    No change in hospital admission and ED use    		100
    Bodenmann et al,41 2017 (Switzerland)Randomized controlled trialED>5 ED visits/yearI: 125
    C: 125    		Interdisciplinary mobile team developed care plan based on patient's evaluation. Care plan could include assistance for financial entitlements, education, housing, health insurance, and domestic violence support, as well as referral to mental health services, substance abuse treatment, or a PCP. Team also provided care coordination, counseling on substance abuse (if needed) and use of medical services. They also facilitated communication between health care team members.No significant changes in ED visits75
    Brown et al,42 2005 (USA)Before-after studyPrimary care clinic>1 hospital admission/year, >1 chronic condition, and life expectancy judged to be greater than 3 years17Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include referral for diagnostic testing or specialists' services and a review of medication. The team also provided care coordination, psychological support, self-management support, and disease management.↓ ED visits
    ↓ Hospital admissions
    ↓ Length of stay
    No change in health care costs    		25
    Crane et al,43 2012 (USA)Nonrandomized trialED>6 ED visits/year; low family incomeI: 34
    C: 36    		Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include referral for diagnostic testing or specialists' services and review of medication. The team also provided group and individual medical appointments, telephone access to care manager, and group sessions on life-skills support.↓ ED visits
    ↓ ED and inpatient costs
    ↑ Employment status    		75
    Edgren et al,44 2016 (Sweden)Randomized controlled trialED>3 ED visits/6 months, deemed at risk of high health care use and considered to be receptive to interventionI: 8,214
    C: 3,967    		Nurse case manager developed, with patient, a care plan based on patient's evaluation. Care plan could include self-management support, patient education, and referrals to other health and social services. Via regular contact by telephone, case manager provided self-management support to patient. They also facilitated communication and supported interactions with health care providers and social services.↓ Outpatient care
    ↓ Inpatient care
    ↓ ED visits
    ↓ Health care costs    		25
    Grimmer-Somers et al,45 2010 (Australia)Mixed methods studyPrimary care centersVulnerable frequent usersQuant: 37
    Qual: Unknown    		Interdisciplinary care team developed, with patient, care plan based on patient's evaluation. Care plan could include referrals to other health and social services, self-management support, patient education, goal setting, and involvement in peer-led community group. The team also provided support for language, literacy, social support, and transport barriers.↓ ED use
    ↓ Hospital admissions
    ↓ Length of stay
    ↓ Inpatient cost
    ↓ Outpatient attendance
    ↓ Patient reflection on their health and other needs
    ↑ Patient goal-setting    		50
    Grinberg et al,46 2016(USA)Qualitative studyTransitional primary care-postdischarge>2 hospital admissions/6 months with at least 3 of the following criteria:>2 chronic conditions; >5 outpatient medications; lack of access to health care services; lack of social support; mental health comorbidity; substance abuse or use; homeless30Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include access to primary care, review of medication, medical appointment accompaniment, assistance for transport, and financial entitlements. The team also provided care coordination and health navigation after hospital discharge.↑ Patient motivation
    ↑ Self-management
    ↑ Healing relationships    		100
    Grover et al,47 2010 (USA)Before-after studyED>5 ED visits/month or concern about ED use raised by staff or identified by California prescription-monitoring program85Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include referrals to outpatient and social services as well as restriction of narcotics prescriptions. Patients received letters to inform them of the care plan but had no contact with the team. The care plan was entered in the patient's medical records in the ED for easy access to information by the ED staff.↓ ED use
    ↓ Radiation exposure from diagnostic imaging
    ↑ Efficacy of referral
    No change in hospital admissions or most common chief complaint    		75
    Hudon et al,48 2015 (Canada)Qualitative studyPrimary care clinics>3 ED visits and/or hospital admissions/year, >1 chronic condition, and identified by family physician as a frequent user likely to benefit from intervention25 patients
    8 family members    		Nurse case manager developed, with patient and other health care providers, a care plan based on patient's evaluation. Care plan could include referrals to health and social services and interdisciplinary team meetings (including the patient). The case manager also provided self-management support and care coordination.↑ Access to care
    ↑ Communication
    ↑ Care coordination
    ↑ Patient involvement in decision-making
    ↑ Care transition    		50
    McCarty et al,49 2015 (USA)Before-after studyED≥25 ED visits/year or identified by ED staff as frequent user likely to benefit from intervention23Interdisciplinary care team developed, with patient, a care plan based on patient’s evaluation. Care plan could include referrals to health care and social services, goal setting, crisis intervention, restriction of narcotic prescriptions, assistance for transport, financial entitlements, and housing. The team also provided care coordination and supported interactions with community services.↓ ED visits50
    Peddie et al,50 2011 (New Zealand)Nonrandomized trialED≥10 ED visits/yearI: 87
    C: 77    		Interdisciplinary care team developed care plan based on patient’s evaluation. The care plan could include referrals to a PCP and interdisciplinary team meeting (including the patient).No change in ED visits25
    Pope et al,51 2000 (Canada)Before-after studyEDFrequent users who had the potential for high ED use, with at least 2 of the following criteria: chronic condition, complex medical condition, substance abuse user, violent behavior or abusive behavior24Interdisciplinary care team developed care plan based on patient’s evaluation. Care plan could include referrals to health care and social services, restriction of narcotic prescriptions, restriction of ED use, limited interaction with ED staff, and escort by a security guard in the ED. The team also provided counseling and supported interactions with community services.↓ ED visits25
    Reinius et al,52 2013 (Sweden)Randomized controlled trialED≥3 ED visits/6 months with the ability to participate in the study based on medical history, number of medications prescribed, and social factorsI: 211
    C: 57    		Same intervention as Edgren et al (2016)44↓ Outpatient care
    ↓ ED visits
    ↓ Length of stay
    ↓ Health care costs
    ↑ Health status
    ↑ Patient satisfaction
    No change in inpatient care, hospital admissions, or mortality    		50
    Roberts et al,53 2015 (USA)Before-after studyTransitional primary care – post discharge≥2 hospital admissions/6 months or ≥3 hospital admissions/year with ≥1 chronic condition198Interdisciplinary care team developed, with patient, care plan based on patient’s evaluation. Care plan could include goal setting, review of medication, assistance for transport, financial entitlements, and housing. The team also provided self-management support, patient education, health navigation, and care coordination.↓ ED visits
    ↓ Hospital admission
    ↓ Health care costs    		75
    Shah et al,54 2011 (USA)Nonrandomized trialPrimary care center≥4 ED visits or hospital admissions or ≥3 hospital admissions or ≥2 hospital admissions and 1 ED visit/ year, with low family income, uninsured, and not eligible for public health insurance programI: 98
    C: 160    		Case manager developed, with patient, care plan based on patient’s evaluation. Care plan could include referrals to health and social services, goal setting, assistance for transport, financial entitlements, and housing. The case manager also provided care navigation, facilitated communication with health care providers, supported interactions with community services, and provided care transition.↓ ED visits
    ↓ Health care cost
    No change in hospital admissions or length of stay    		50
    Skinner et al,55 2009 (UK)Before-after studyED≥10 ED visits/6 months or identified by senior health care providers as putting a high demand on unscheduled care services (or at future risk) and who could benefit from intervention57Interdisciplinary care team developed care plan based on patient’s evaluation. The care plan could include referrals to health care services.↓ ED visits75
    Sledge et al,56 2006 (USA)Randomized controlled trialPrimary care center≥2 hospital admissions/yearI: 47
    C: 49    		Same intervention as Brown et al (2005)42↑ Clinic visits
    No change in health care use or costs, functional status, patient satisfaction, or medication taking adherence.    		50
    Spillane et al,57 1997 (USA)Randomized controlled trialED≥10 ED visits/yearI: 27
    C: 25    		Interdisciplinary care team developed care plan based on patient’s evaluation. Care plan could include care recommendation and treatment guidelines for ED staff such as limitation of diagnostic tests and restriction of narcotics prescriptions. The team also provided psychosocial services, care coordination, and liaison with a PCP.No change in ED visits75
    Stokes-Buzzelli et al,58 2010 (USA)Before-after studyEDTop 100 frequent ED users, or identified as frequent users deemed appropriate for intervention36Interdisciplinary care team developed care plan based on patient’s evaluation. The care plan could include care suggestions and treatment guidelines (eg, restriction of narcotics prescriptions) for ED staff.↓ ED visits
    ↓ ED contact time
    ↓ Laboratory tests ordered
    ↓ ED costs    		75
    Weerahandi et al,59 2015 (USA)Nonrandomized trialTransitional primary care – postdischarge≥1 hospital admission/1 month or 2 hospital admissions/6 monthsI: 579
    C: 579    		Social worker case manager, with patient and other health care providers, developed care plan based on patient’s evaluation. Care plan could include referrals to health care and social services, counseling for mental health problems, self-management support, patient activation, assistance with insurance, and medical appointment accompaniment. The case manager also provided care coordination and care transition and facilitated communication between health care providers.No change in hospital admissions50

    • C = control group; CM = case management; ED = emergency department; I = intervention group; PCP = primary care provider; Qual = qualitative study; Quant = quantitative study; UK = United Kingdom; USA = United States of America.

  • Table 2

    Truth Table

    Case-Management IntensityCase FindingMultidisciplinary/Interdisciplinary Care PlanPositive OutcomeNo. of CasesCases
    11119Adam et al,40 Brown et al,42 Crane et al,43 Grimmer-Somers et al,45 Grinberg et al,46 Hudon et al,48 McCarty et al,49 Pope et al,51 Roberts et al53
    11013Edgren et al,44 Reinius et al,52 Shah et al54
    01113Grover et al,47 Skinner et al,55 Stokes-Buzzelli et al58
    10104Bodenmann et al,41 Sledge et al,56 Spillane et al,57
    Weerahandi et al,59
    00101Peddie et al50

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  • The Article in Brief

    Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review

    Catherine Hudon , and colleagues

    Background Case management for complex patients does not always improve outcomes, but in this systematic review, researchers identified three characteristics of case management programs that consistently yielded positive results.

    What This Study Found This review included data from 20 studies, 17 of which were quantitative, of adult frequent users with chronic diseases in primary, secondary and tertiary care settings. Case management was delivered in a primary care setting in all of the studies. Factors such as health care system use, financial cost and patient outcomes were the primary outcomes assessed. All the case management interventions with positive outcomes included some method of identifying a sub-group of frequent users most likely to benefit. The characteristics most commonly leading to positive results included case selection for frequent users with complex problems, high-intensity case management interventions and a multidisciplinary care plan.

    Implications

    • Most of the methods with positive outcomes included high-intensity case management interventions and care plans developed by multidisciplinary teams. The author suggests that policymakers and clinicians should focus on finding patients most likely to benefit from case management. A high-intensity case management intervention and/or access to a multidisciplinary team may also improve outcomes.
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