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ABSTRACT
Purpose of the Study: To examine the effects of a community-based case management program on acute
health care utilization and associated costs in uninsured patients with 1 or more chronic diseases.
Primary Practice Setting: Large regional academic medical center that provides health care services for the
vast majority of indigent patients in the area.
Methodology and Sample: This was a retrospective study of 83 patients who enrolled in a case management
program between April 2007 and August 2008 on the basis of 1 or more emergency department visits or acute
hospitalizations. Paired t tests were used to compare utilization and costs before and after enrollment.
Results: Overall, acute outpatient encounters decreased by 62% and inpatient admissions by 53%, whereas
primary care visits increased by 162%. Participation in the case management program was also associated with
a 41% reduction in overall aggregate costs, from $16,208 preintervention to $9,541 postintervention ( p .004).
Implications for Case management Practice: The results of this study suggest that intensive case
management can reduce acute care utilization and costs and increase primary care follow-up among uninsured
patients with certain chronic diseases.
Key words: case management, chronic diseases, emergency care, medical indigency, primary health care
Many newly unemployed and uninsured Americans have turned to public insurance programs in the
wake of what has been characterized as the worst
financial meltdown since the Great Depression. Medicaid enrollment increased by 17.8% between the
start of the recession in December 2007 and June
2010. By the end of June 2010, more than 50 million persons were enrolled in Medicaidthe largest
number of enrollees in the history of the program
(Kaiser Commission on Medicaid and the Uninsured,
2011). Even though Medicaid has provided a safety
This study was presented in part at the 139th Annual
Meeting of the American Public Health Association,
Washington, DC, November 1, 2011.
Address correspondence to Alison Glendenning-Napoli,
BSN, RN-BC, Community Health Program, University of
Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555 (alglende@utmb.edu).
The authors report no conflicts of interest.
DOI: 10.1097/NCM.0b013e3182687f2b
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METHODS
Sample
The study population consisted of a convenience
sample (i.e., nonprobability sample; see the Limitations section) of 83 patients without medical insurance who volunteered to participate in an intensive
case management program at the University of Texas
Medical Branch (UTMB) between April 1, 2007, and
August 31, 2008. Criteria for inclusion in the study
included: (1) a diagnosis of diabetes mellitus, essential hypertension, congestive heart failure, or coronary artery disease (alone or in combination); (2) a
history of at least one inpatient admission or acute
outpatient encounter (i.e., emergency department
visit, outpatient day surgery, or hospital observation
but not admission) at the UTMB within 12 months
before enrollment; and (3) participation in the case
management program for a minimum of 6 months,
including at least two encounters with a case manager. Patients with a co-occurring serious mental illness or substance abuse problem were not eligible for
enrollment. Each patients primary and secondary
diagnoses were established at the time of the initial
acute outpatient visit or inpatient admission and classified according to the International Classification
of Diseases, Ninth Revision, Clinical Modification.
During the 17-month study period, a total of 363
eligible patients were identified. In spite of multiple
attempts, 266 of the patients could not be contacted
for various reasons (e.g., did not return phone calls,
disconnected phones). Another 14 patients who were
contacted declined to enroll. This left a study sample
of 83 patients. Recruitment of additional study subjects and a longer follow-up period were not possible
because of Hurricane Ike, which made landfall in
Galveston, TX, in September 2008. The storm inundated more than 100 buildings on the UTMB campus
with up to 10 feet of water, necessitating the closure of
all clinics and hospitals and the temporary suspension
of most indigent care services, including the intensive
case management program (Lozano, 2008; Ortolon,
2009). The study was reviewed and approved by the
UTMB institutional review board.
Intervention
The UTMB Community Health Program implemented a case management program in 2007 with
the goal of reducing potentially avoidable hospitalizations and acute care visits, while increasing access
to primary care for uninsured patients with select
chronic diseases. Patients who are eligible for the
program are identified on the basis of a hospitalization, acute outpatient encounter, or recurring clinic
visits. A case manager, who is a registered nurse,
then contacts the patient by telephone, provides an
overall description of the program, and invites the
patient to enroll. If the patient agrees to participate,
the case manager schedules a home visit to enroll the
patient and conduct a needs assessment that focuses
on identifying barriers to accessing health care and
determining the patients health literacy level, especially knowledge of his or her medical condition and
how to manage it. The case manager then develops
a preventive care regimen tailored to the specific
needs of the patient. A masters-level social worker
assists the case manager in identifying the patients
need for public health programs and social services
(e.g., county indigent health care program, Medicaid,
disability, housing, and food assistance). Additional
home visits are scheduled on an as-needed basis to
assist patients in the day-to-day management of their
chronic condition, such as education about the correct use of glucometers and blood pressure monitors, dietary and lifestyle modifications, and strategies to enhance adherence to prescribed medication
regimens. Case managers also provide medication
education sessions and help patients apply for pharmacy assistance programs. In addition, case managers accompany patients to their provider/clinic visits
in an effort to better engage the patients in their care
and promote a positive, effective relationship with
their primary care provider. The case manager then
reinforces the interventions with telephonic followup or further home visits or both to check progress,
answer questions, and provide support.
Data Collection
Two data sources were used: an administrative billing database maintained by the UTMB Department of
Finance and an electronic clinical information system
and registry (Patient Electronic Care System, Aristos
Group, Inc., Austin, TX) maintained by the UTMB
Community Health Program. The administrative
database was used to identify all clinical encounters
(i.e., inpatient admissions, acute outpatient encounters, and clinic visits) that occurred during the study
period and were related to treatment for any of the
four chronic diseases under study and also to identify the costs associated with these services. The clinical information system was used to determine the
patients demographic characteristics (age, gender, and
race/ethnicity) and the duration of active participation
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TABLE 1
Demographic and Clinical Characteristics
of Sample
Statistical Analysis
Health care utilization and associated costs before
enrollment in the case management program were
compared with an equal period of time after enrollment for each individual. For example, if a patient
was enrolled for 10 months, we compared utilization
and cost history for the period of 10 months prior to
enrollment with the 10-month period during enrollment. Because parallel health care utilization and cost
data were collected before and after enrollment in the
program, analyses were conducted such that each
patient served as his or her own historical control.
Statistical analyses were conducted using SAS software, version 9.1.3 (SAS Institute, Cary, NC). Paired
t tests were used to compare the mean differences
for both health care utilization and associated costs
before and after the intervention. All of the analyses were stratified across gender, race/ethnicity, and
age. Administrative costs of the intervention program
itself (e.g., enrolling patients, providing intervention
services) were not included in our cost analyses.
Statistical significance was defined as a p value of less
than .05.
RESULTS
Table 1 presents the demographic and clinical characteristics of the study cohort. Of the 83 patients in
the sample, 60.2% were female, 51.8% were nonHispanic White, and 73.5% were between 50 and
65 years of age. Patient age at the time of enrollment
in the case management program ranged between
18 and 65 years. Of the four chronic diseases under
study, hypertension was the most prevalent among
the cohort (88.0%), followed by diabetes (53.0%),
coronary artery disease (42.2%), and congestive heart
failure (30.1%). The vast majority of the patients
(84.3%) had more than one of the four chronic diseases. Most of the patients (67.5%) had participated
in the intervention program for 12 months or longer
(see Table 2).
Participation in the case management program was
associated with statistically significant reductions in
both acute outpatient encounters and inpatient admissions along with a concomitant increase in primary
care clinic visits (see Table 3). The mean number of
acute outpatient encounters declined from 0.70 before
enrollment in the program to 0.27 after enrollment
(p .0007); inpatient admissions declined from a mean
of 1.24 to 0.58 (p .0001). Conversely, clinic visits
increased from a mean of 4.13 to 10.82 (p .0001).
All demographically stratified analyses showed similar
270
Total Sample
Males
Females
83 (100)
33 (39.8)
50 (60.2)
Non-Hispanic White
43 (51.8)
15 (45.5)
28 (56.0)
Hispanic
19 (22.9)
6 (18.2)
13 (26.0)
African American
21 (25.3)
12 (36.4)
9 (18.0)
N (%)
Dempographic characteristics
Race/ethnicity
22 (26.5)
10 (30.3)
12 (24.0)
5065
61 (73.5)
23 (69.7)
38 (76.0)
Diabetes
44 (53.0)
16 (48.5)
28 (56.0)
Hypertension
73 (88.0)
29 (87.9)
44 (88.0)
25 (30.1)
14 (42.4)
11 (22.0)
35 (42.2)
13 (39.4)
22 (44.0)
Clinical characteristics
Chronic diseases
Comorbidity
Only 1 chronic disease
13 (15.7)
4 (12.1)
9 (18.0)
2 chronic diseases
18 (21.7)
8 (24.2)
10 (20.0)
3 chronic diseases
28 (33.7)
13 (39.4)
15 (30.0)
4 chronic diseases
24 (28.9)
8 (24.2)
16 (32.0)
TABLE 2
Duration of Participation in Community
Health Program (Cohort of 83 Patients)
Months
6 to 8
6.0
8 to 10
2.4
10 to 12
20
24.1
12 to 14
48
57.8
-8
9.6
1417
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TABLE 3
Comparison of Health Care Utilization Before and After Enrollment in Community Health Program
Acute Outpatient Encountersa
Pre-CHP,
M (SD)
Post-CHP,
M (SD)
0.70 (0.95)
Female (n 50)
Male (n 33)
Inpatient Admissions
Pre-CHP,
M (SD)
Post-CHP,
M (SD)
0.27 (0.61)
.0007
1.24 (1.09)
0.58 (1.00)
0.70 (1.05)
0.24 (0.59)
.008
1.18 (1.02)
0.60 (0.97)
0.70 (0.77)
0.30 (0.64)
.04
1.33 (1.19)
0.55 (1.06)
0.60 (0.93)
0.33 (0.71)
.12
1.33 (1.13)
0.74 (1.16)
Hispanic (n 19)
0.84 (1.12)
0.11 (0.46)
.02
1.16 (0.96)
0.32 (0.48)
0.76 (0.83)
0.29 (0.46)
.01
1.14 (1.15)
1849 (n 22)
1.09 (1.41)
0.32 (0.57)
.02
5065 (n 61)
0.56 (0.67)
0.25 (0.62)
.01
Characteristics
Total sample (N 83)
Clinic Visits
p
Pre-CHP,
M (SD)
Post-CHP,
M (SD)
.0001
4.13 (4.01)
10.82 (9.08)
.0001
.0001
4.68 (4.29)
11.06 (8.84)
.0001
.004
3.30 (3.44)
10.45 (9.56)
.0001
.005
3.79 (4.39)
11.47 (9.53)
.0001
.0003
4.79 (3.44)
9.42 (5.94)
.004
0.48 (0.98)
.02
4.24 (3.75)
10.76 (10.62)
.004
1.54 (1.41)
0.77 (1.07)
.03
3.59 (3.91)
11.32 (10.58)
.001
1.13 (0.94)
0.51 (0.98)
.0001
4.33 (4.06)
10.64 (8.56)
.0001
Gender
Race/ethnicity
encounters decreased by 62%, from $1,830 preenrollment to $700 postenrollment; mean cost for inpatient admissions decreased by 53%, from $13,341 to
$6,324; and mean cost for primary care visits increased
by 143%, from $1,036 to $2,517. When stratified by
gender, men showed a greater percentage decrease in
costs than women for both acute outpatient encounters (69% vs. 57%; p .03) and inpatient admissions
(58% vs. 49%; p .01). When stratified by race/ethnicity as well as age, statistically significant reductions
in inpatient admission costs were observed among
non-Hispanic Whites (p .01), African Americans (p
.03), and patients between 50 and 65 years of age
(p .01). However, a statistically significant reduction
in costs for acute outpatient encounters was observed
only among African American patients (p .04). The
increase in the postenrollment costs for clinic visits did
not reach statistical significance when analyzed across
any of the demographic strata. The mean aggregate
health care utilization cost per patient decreased by
TABLE 4
Comparison of Health Care Encounters
Before and After Enrollment in Community
Health Program
Number of Encounters
Type of Encounter
Pre-CHP
Post-CHP
Percent
Change
58
22
62.1
Inpatient admissions
103
48
53.4
343
898
161.8
41%, from $16,208 preintervention to $9,541 postintervention (p .004) (see Table 6). When stratified
by demographic characteristics, statistically significant
reductions in mean aggregate costs were observed
among men (p .03), non-Hispanic Whites (p .02),
and patients between 50 and 65 years of age (p .01).
DISCUSSION
In this study of uninsured patients with one or more
chronic diseases, the introduction of an intensive case
management program was associated with statistically significant reductions in acute health care utilization and a concomitant increase in primary care
clinic visits. Overall, acute outpatient encounters
decreased by 62% and inpatient admissions by 53%
whereas primary care visits increased by 162%. Participation in the case management program was also
associated with a 41% reduction in overall aggregate
costs, from $16,208 preintervention to $9,541 postintervention (p .004).
Only a few studies have evaluated the impact of
case management interventions on health care utilization and costs among patients without medical
insurance. A direct comparison of our results with
these earlier studies is difficult because of differences
in study designs, methods, and outcome measures.
Wetta-Hall (2007) analyzed the outcomes of a convenience sample of 492 uninsured patients who enrolled
in a case management program that was based on
a model similar to ours. Half of the sample had a
history of chronic illness. At 6 months postintervention, the total number of emergency department visits
among the sample had declined by 48%. On the basis
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TABLE 5
Comparison of Health Care Utilization Costsa Before and After Enrollment in Community Health
Program
Acute Outpatient Encountersb
Characteristics
Total sample (N 83)
Pre-CHP,
M (SD)
Post-CHP,
M (SD)
1,830 (3,087)
Inpatient Admissions
Clinic Visits
Pre-CHP,
M (SD)
Post-CHP,
M (SD)
Pre-CHP,
M (SD)
Post-CHP,
M (SD)
700 (2,224)
.009
13,341 (21,400)
6,324 (12,390)
.002
1,036 (1,059)
2,517 (5,456)
.02
Gender
Female (n 50)
1,801 (3,436)
776 (2,594)
.10
12,737 (24,056)
6,522 (12,291)
.05
1,178 (1,159)
2,206 (4,592)
.13
Male (n 33)
1,875 (2,518)
584 (1,534)
.03
14,258 (16,911)
6,024 (12,724)
.01
822 (858)
2,998 (6,604)
.06
Non-Hispanic White
(n 43)
1,453 (2,860)
941 (2,829)
.40
16,655 (22,158)
8,483 (15,079)
.01
941 (1,143)
2,277 (4,751)
.07
Hispanic (n 19)
2,397 (3,813)
331 (1,441)
.05
11,822 (27,911)
4,616 (8,880)
.27
1,235 (1,007)
1,367 (981)
.63
African American
(n 21)
2,090 (2,852)
541 (1,153)
.04
7,931 (9,431)
3,449 (7,709)
.03
1,052 (940)
4,049 (8,362)
.12
Race/ethnicity
1,909 (3,662)
438 (1,084)
.09
20,227 (31,238)
8,064 (14,002)
.09
862 (1,002)
2,700 (5,049)
.10
5065 (n 61)
1,802 (2,886)
794 (2,513)
.05
10,858 (16,146)
5,697 (11,818)
.01
1,099 (1,080)
2,450 (5,634)
.07
of the assumption that the rate of emergency department visits would remain the same in the absence of
interventions, the author not only estimated that case
management resulted in a charge avoidance of nearly
$1.5 million but also cautioned that the cost savings
might be overestimated because the costs of primary
care services were not measured directly. Like those
TABLE 6
Aggregate Costs of Health Care Utilization
Before and After Enrollment in Community
Health Program
Aggregate Costsa
Characteristics
Total sample (N 83)
Pre-CHP,
M (SD)
16,208 (21,265)
Post-CHP,
M (SD)
9,541 (13,681)
p
.004
Gender
Female (n 50)
15,715 (24,061)
9,504 (13,373)
.05
Male (n 33)
16,954 (16,473)
9,597 (14,344)
.03
Non-Hispanic
White (n 43)
19,048 (22,254)
11,700 (15,994)
.02
Hispanic (n 19)
15,454 (27,423)
6,314 (9,180)
.16
African American
(n 21)
11,073 (9,573)
8,039 (11,492)
.25
1849 (n 22)
22,998 (30,948)
11,203 (14,969)
.10
5065 (n 61)
13,759 (16,118)
8,942 (13,266)
.01
Race/ethnicity
272
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In this study of uninsured patients with one or more chronic diseases, the introduction
of an intensive case management program was associated with statistically significant
reductions in acute health care utilization and a concomitant increase in primary care
clinic visits. Overall, acute outpatient encounters decreased by 62% and inpatient
admissions by 53% whereas primary care visits increased by 162%. Participation in
the case management program was also associated with a 41% reduction in overall
aggregate costs, from $16,208 preintervention to $9,541 postintervention (p .004).
LIMITATIONS
The results of this study should be interpreted in
the context of several limitations. Because our study
utilized a nonprobability sample (i.e., a convenience
sample) rather than a probability sample (e.g., a
random sample), it is possible that our results were
affected by selection bias and are not generalizable to
the large group of eligible patients who did not enroll
in the program. That is, the subgroup of patients who
chose not to participate in the intervention may have
been less motivated to improve their health or may
have had more complex health or socioeconomic
problems (Wetta-Hall, 2007). Furthermore, because
our study was limited to an uninsured population
from a relatively small geographic area served by a
single hospital, it is unclear whether our findings can
be generalized to populations from other geographic
regions. In addition, our results may not generalize to
those patients who were ineligible for the intervention because of co-occurring psychiatric disorders.
Another limitation was the small sample size in our
study. Finally, because we did not factor in the administrative costs of the intervention program itself in
our calculations, it is possible that the cost savings
associated with the intervention were overestimated.
CONCLUSIONS
Clinical case management programs have become
increasingly popular as a strategy to curb excessive and expensive health care services, particularly
in persons with chronic diseases and those who are
uninsured or underinsured. Nonetheless, only a few
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studies have evaluated the effectiveness of case management interventions in meeting this goal. In spite of
its limitations, our study provides additional evidence
that intensive clinical case management can reduce
acute care utilization and costs and increase primary
care follow-up in uninsured patients with chronic diseases. We believe that the results of our study may
be applicable to other safety net institutions that are
struggling to cope with escalating health care costs
and the growing number of uninsured persons. Additional studies with randomized designs and large
sample sizes are needed to validate our findings and
to identify the most effective components of case
management interventions.
ACKNOWLEDGMENTS
We thank Mary Lou Wallin for assistance in data
compilation, Leonard Pechacek for editing and writing assistance, and Jacques Baillargeon, PhD, for critical review of the manuscript.
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