Health Care Challenge

While there is evidence that shows integrated care models can improve outcomes for those with MCC, they have yet to be widely implemented.

This study compares three ways health systems can deploy resources and care management support to individuals with MCCs after a hospital stay to better manage their future health.

Goals

At the end of this study, health systems should be able to better answer the following questions:

• How do in-person and remote care management programs influence patient-centered outcomes? For example, which mode of care management delivery helps people living with MCCs to better manage their conditions at home and/or go to the hospital less frequently?
• What mode of care delivery works best for whom? For example, do adults over the age of 60 benefit more from an in-person approach? When is a remote monitoring approach most impactful for improving someone’s ability to manage their health?
• What supports someone’s engagement in care management? What are barriers to working with care managers who deliver care in-person or remotely?

Implementation Approach

Population

Patients, ages 21 and over, with multiple chronic conditions— including one physical health condition and at least one additional physical or behavioral health condition— who have been discharged from an inpatient hospital stay within the past 30 days.

Methodology

Methodology: Compare the impact of three different modes of care delivery on hospital readmission, health status, and patient activation.

• High-Tech: Care Managers leverage the use of video calls, digital check-in messages, and telephonic support to assist participants in connecting to resources and managing their health for four months to one year following an inpatient hospital stay.
• High-Touch: Care Managers provide intensive in-person and/or telephonic support to assist participants in connecting to resources and managing their health four months to one year following an inpatient hospital stay.
• Usual Care: This is the current standard of post-discharge support. Care Mangers provide one in-home or one telephonic visit after an inpatient hospital visit, and then connect a participant and/or caregiver to support and services.

Participants completed surveys at the time of enrollment, and at 3, 6, and 12-month timepoints to report on changes in health status, patient activation, physical function, quality of life, and care satisfaction.

Participants and care management staff completed qualitative interviews to share about challenges and benefits to engaging and/or implementing High-Tech and High-Touch care management strategies.

The study design, implementation, and results interpretation are stakeholder-driven, advised by a patient partner workgroup, a patient-partner co-investigator, and a stakeholder advisory board of health providers, caregivers, patients, researchers, payers, policy makers, and community organizations. An intervention champions network comprised of individuals who participated in the study will also support the interpretation and sharing of study results.