EXECUTIVE SUMMARY

Primary care intensive management uses some case management tactics to closely follow patients with chronic and complex illnesses to improve their usual primary care.

  • A study among five Veterans Affairs hospital sites did not reveal many differences in medication management, and no differences in reducing hospitalizations, emergency department visits, and costs.
  • The intensive management team conducts medication reconciliation and helps people fill their pill boxes.
  • The program appeared to help diabetic patients who faced greater challenges to their disease management.

A case management-type of model, called primary care intensive management, could provide some limited benefits for more complex patients, research shows. But the research also suggests questions about how population health resources are best spent.1

“We performed a pilot program in the VA [Veterans Affairs], based in five sites across the country, where we implemented something called intensive primary care,” says Jean Yoon, PhD, MHS, investigator with the VA Health Economics Resource Center at VA Palo Alto Healthcare System in Menlo Park, CA. “There are patients who are sicker than the average patient and have more complex, more chronic conditions, and social and mental conditions that complicate their care. They have a lot of utilization and are at high risk for future hospitalizations. Our project attempted to intervene with these patients by implementing intensive primary care.”

The project leaders used an algorithm to find patients, then randomized them to regular primary care or intensive primary care.1,2 Primary care intensive management involves an interdisciplinary team of physicians, nurses, mental health specialists, social workers, and others. They perform chart reviews to determine the care patients are receiving and identify any gaps.

“They did home visits as part of the needs assessments and saw how patients were managing their chronic condition in the home environment,” Yoon says. “After the needs assessment, they determined which services the patient might benefit from.”

For instance, patients might need more care coordination, referrals, and medication management help. The team performed medication reconciliation, reviewing patients’ prescriptions with them and helping them understand their medications and when to take them. The team also helped patients use pill boxes, obtain refills, dispose of expired medications, and improve their life circumstances and instability when obstacles to medication adherence appeared, Yoon explains. “Helping patients fill pill boxes seems small, but patients really liked that.”

Medication Adherence Largely Unaffected

Yoon and colleagues found high-risk patients demonstrated similar rates of medication adherence to patients in usual primary care with one exception: The intervention group saw a significant increase in adherence for DPP-4 inhibitors, which are used to treat patients who have not responded to other diabetes drugs or have problems with formulary medications. The intensive management program was better for patients who faced greater challenges to their diabetes management, the authors concluded.1

“We wanted to see if there were any differences in medication adherence and adjustments,” Yoon explains. “We found their adherence was pretty high to begin with. We did find the team had some positive impact on the patients — but, overall, the impact was somewhat mild.”

The team also screened patients for mental health issues and helped them with mental health referrals. Patients might experience depression, post-traumatic stress disorder, bipolar disorder, or other problems that could be treated by mental health professionals.

“Some of these can be treated in primary care, and some needed specialty mental healthcare,” Yoon says. “A lot of times, there were mental health specialists as part of the team who could provide the mental healthcare themselves.”

In the original study on the program, published in 2018, the primary care intensive management program did not produce any reductions in hospitalizations, costs, or ED visits.2

“It did look like there was some offsetting of costs — some higher outpatient and lower inpatient costs,” Yoon says. “The lower inpatient costs were not specifically significant, but were offsetting with higher outpatient costs.”

As evaluations of similar programs have shown, including evaluations of randomized care coordination programs for chronically ill Medicare beneficiaries, most do not reduce hospitalizations or costs. Other research showed intensive outpatient care can positively affect patient experiences.2

Resource-Intensive, but Few Results

The primary care intensive management program required substantial resources to assess high-risk patients’ needs and tailor services to meet their goals for long-term health improvements. It also facilitated referrals to a variety of additional services, including palliative, hospice, geriatrics, specialty mental health, and telehealth care. “Over five sites, they did it all differently,” Yoon notes. “It depended on the patient and their needs.”

For instance, some patients might need only a couple of visits with the team, but others needed more visits over a one- or two-year period. “Not all patients who were assigned intensive teams received services from them,” Yoon explains. “The team decided which patients would benefit from their services, so some patients got really good care from primary care. They didn’t feel like they needed additional care.”

The team conducted in-person assessments with patients to determine their needs. Patients could refuse the extra services, if they desired.

The study’s design might have affected the results. “We underpowered our results by not giving [intensive management] to every patient randomized,” Yoon says. “Not every patient was a perfect fit, so only a minority of patients got intensive management.”

When the intensive management team conducted a needs assessment, they found many patients were already receiving good primary care and would not benefit from the intensive management team.

The VA implemented the patient-centered medical home model before the primary care intensive management study. That might have been one of the reasons the results were similar between the primary care group and the group that received intensive management. “We think the VA was already providing pretty good primary care,” Yoon says. “The other factor is these patients were very sick, and even though more care was provided to them, it wasn’t enough to impact ED visits and hospitalization costs. Even with an improvement in care, they were sick enough to have a high rate of hospitalization.”

The researchers found that primary care intensive management may need to focus more on patients amenable to intervention to see a significant effect on outcomes.1

The findings suggested that when healthcare resources are used to make critically ill patients healthier, they should be more focused on the population targeted to be both efficient and effective.

“This was an expensive intervention, treating a relatively small number of patients at each site,” Yoon notes. “The VA now is focusing more on improving regular primary care and developing tools in regular primary care to manage these very sick patients.”

REFERENCES

  1. Yoon J, Wu F, Chang E. Impact of primary care intensive management on medication adherence and adjustments. Am J Manag Care 2020;28:e239-e245.
  2. Yoon J, Chang E, Rubenstein LV, et al. Impact of primary care intensive management on high-risk veterans’ costs and utilization. Ann Intern Med 2018;168:846-854.