Exploring and Overcoming the Challenges Primary Care Practices Face with Care Management of High-Risk Patients in CPC+: a Mixed-Methods Study

Abstract

BACKGROUND: Longitudinal care management (LCM) for high-risk patients is a cornerstone of primary care models aiming to improve quality and reduce costs. OBJECTIVE: Describe the extent to which LCM was implemented in the second year of Comprehensive Primary Care Plus (CPC+), and barriers to and facilitators of implementation. DESIGN: Mixed-methods. PARTICIPANTS: Quantitative: 2715 practices participating in CPC+ in 2018. Qualitative: Interviews with practitioners and staff in 23 representative CPC+ practices. MAIN MEASURES: Across all CPC+ practices, we report median percentages of empaneled patients placed in the highest-risk tiers and, of those, the median percentage receiving LCM. Across 23 CPC+ practices, we report qualitative findings on LCM implementation. KEY RESULTS: While practices reported benefits of LCM, a small proportion of patients received LCM. Practices placed 2.4% (median) of patients in the highest-risk tier; of these, 30% (median) received LCM. Practices placed 10% (median) of patients in the second-highest-risk tier; of these, 7% (median) received LCM. Interviews revealed LCM uptake across tiers was low because of insufficient care manager staffing. Other challenges included lack of practitioner buy-in to using risk stratification to identify high-risk patients, patients' reluctance to engage in LCM or change behaviors, and limited health information technology functionality for developing, maintaining, and accessing high-risk patients' care plans. Facilitators included embedding care managers within practices and electronic health record functionalities that support LCM. CONCLUSIONS: Despite substantial financial and other supports, and practices' perceived benefits of LCM, insufficient care manager staffing and other barriers have limited its potential in CPC+ to date. To expand LCM's reach, practices need additional care managers, training to overcome barriers to patient engagement, better identification of patients who might benefit from LCM, improved information technology tools for risk stratification and care plans, and more practitioner buy-in to risk stratification.

Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada

“…Strong leadership and active support from primary care providers and health services managers increased stakeholders and nurse case managers engagement, facilitating the implementation of the intervention. These factors and their respective impacts are noted in the literature [ 52 – 54 ]. The selection of skilled nurse case managers also helped facilitate the implementation of a successful CMI initiation.…”

“…It was difficult for nurse case managers to access and share patient health information, which acted as a barrier to the setting up the intervention. Standardized methods of data entry, such as the use of electronic medical records for developing, maintaining, and accessing patient care plans could facilitate the implementation of CMI [ 16 , 52 ]. However, even if shared health information technology improves care access, quality, and coordination, and decreases the costs of care [ 56 – 60 ], it may conflict with the ethical principles of patient consent, data confidentiality, and equity in health resources distribution [ 57 ].…”

What Is the Return on Investment of Caring for Complex High-need, High-cost Patients?

“…Overall, only 38% (n=726/1901) of high-risk patients eventually received intensive case management services, similar to other non-VA settings. 21 During the second phase, the demonstration sites accepted referrals that met eligibility criteria (i.e., high-risk score). We found that the proportion of patients engaged by the program from referrals was higher (73%; 263/364) than that of patients who were identified through administrative data alone (38%).…”

Factors Associated With Patient-Centered Medical Home Teams' Use of Resources for Identifying and Approaches for Managing Patients With Complex Needs

“…The challenges and costs of caring for patients with complex health and psychosocial needs in primary care are well documented (Hayes et al, 2016; Higgins et al, 2021; Peikes et al, 2018). These patients often have multiple chronic medical conditions compounded by mental illness, substance abuse, or other social circumstances (homelessness, unemployment, food insufficiency, etc) that contribute to their disproportionately high utilization of expensive inpatient and acute care (Hasselman, 2013; Hunter et al, 2015; Zulman et al, 2015).…”