A small segment of the population accounts for the majority of health care spending. These individuals are disproportionately likely to be adults over 65 years old who are frequent users of health care services due to multiple chronic conditions, and/or functional impairment. These ?high need, high cost? older adults are more likely to experience fragmented care, hospitalizations for preventable conditions, lab and medication errors, and dissatisfaction with their care. Care management programs may be a promising approach for this population. Changes in the health care environment have led to a proliferation of these programs; estimates suggest that 3 times as many care management programs exist today as just 10 years ago. Many of these programs are currently developed within independent entities such as outpatient clinics, acute care hospitals and accountable care organizations that do not traditionally collaborate; meaning, more than one program may unknowingly attempt to manage the care of a single individual. It is not clear how care management programs co-exist in the care of the high need, high cost older adult population. This proposal aims to fill this important gap by assessing the scope, nature and effects of co-existence of care management programs which target high need high cost older adults.
Aim 1 focuses on care management programs from a number of potential sources (health plans, primary and specialty outpatient care, acute inpatient care, and home care) within a large academic health system. Structured surveys of program administrators will assess program characteristics. Data on enrolled patients from these programs will be cross-matched and linked with aggregated health care utilization data to examine the population size, demographic and clinical characteristics of high need, high cost older adults who are enrolled in co-existing care management programs.
Aim 2 extends Aim 1 findings by conducting in-depth interviews and qualitative data analysis to explore the perspectives of high need, high cost older adults and frontline program staff (i.e.- case managers) regarding perceived and observed effects of co-existing care management services on ability to manage health and coordinate care. The academic health system in which this proposal takes place sits within a regional partnership of health systems. The findings here will be the basis of future work that studies the larger landscape of care management program co-existence across the entire regional partnership. This innovative work addresses how care management programs from multiple sources can co-exist in the care of high need, high cost older adults. Without understanding how programs co-exist, it will be difficult to attribute outcomes to any one intervention, stalling progress towards identifying best practices and improving care for this vulnerable population. The proposed project will support the career development of the candidate, who aims to become an independent clinician investigator focused on identifying best practices to improve care of high need, high cost older adults.

Public Health Relevance

With increasing focus on value based payment and population health initiatives, payers, outpatient clinics and hospitals are independently creating care management programs aimed at the subset of the population with the most utilization and care needs- high need, high cost older adults. With so many separate programs targeting a relatively small subset of the population, it is not clear how programs co-exist or the effects of co- existence on care. This study aims to evaluate the nature, scope and effects of co-existing care management programs on high need, high cost older adults, which will inform the development and evaluation of best practices to improve population health and individual care of high need, high cost older adults.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Small Research Grants (R03)
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Special Emphasis Panel (ZAG1)
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Salive, Marcel
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Johns Hopkins University
Internal Medicine/Medicine
Schools of Medicine
United States
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