Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 2. The Structure of Care Management


The lack of a dominant care management model that has been shown to save money is reflected in the diverse approaches used by the four case study organizations. While all four have such programs, they differ along a number of dimensions. The most important differences appear to be the scale of the programs, whether care managers interact with patients face-to-face or only by telephone, the location of care management staff in proximity to primary care physicians, the staffing structures, and the duration of active care management services.

Scale. At the time of our visit, only Keystone East had a care management program that was available to all seniors, including those enrolled with capitated provider units. Care management activities at HMO Oregon reflected the overall division of risk at that plan. The medical groups capitated by HMO Oregon had responsibility for care management for their patients, while HMO Oregon provided care management to enrollees whose primary care physicians were not part of capitated practices. Kaiser Colorado had formal care management only at the two clinics participating in its pilot program. After completing an internal evaluation of this pilot, which suggested that care management could save money, Kaiser Colorado decided to expand the care management to all its clinics. Aspen’s care management program, which received a substantial part of its funding from Medica Health Plan, served only those patients enrolled with Medica.

Location. Aspen and Kaiser Colorado located care managers in their clinics, so that the care managers could have face-to-face contact with patients and primary care physicians. Keystone East centralized its care managers, who then conducted all patient contact over the telephone. Each care manager was given a specific geographic region in order to promote communication with the set of physicians who also served that area. HMO Oregon used both approaches (co-location and separate location), which reflects its delegation of risk and care responsibility to capitated provider groups. At all four organizations, home health staff were used to conduct home evaluations, and there were special programs to help manage care for people in nursing homes.

Mode of Contact with Patients. As noted, in Keystone East’s care management program, patient contact was done exclusively over the telephone. If a face-to-face communication with the patient or family member was required, it was made by staff from a contracted home health agency. Care managers were assigned to all physicians who admit at a particular hospital. This approach is intended to ensure that the care manager is knowledgeable about local social service resources, and to promote good relations with primary care physicians. However, the physicians who participated in our focus group reported having little contact with care managers, which indicates that assignment to a limited number of physicians does not guarantee effective communications.

HMO Oregon relied heavily on telephone contact, but care managers did occasionally meet with patients or family members. Care managers also performed home visits, although more commonly the contracted home health agency performed this task.

The two care managers at Kaiser Colorado routinely met with patients in the clinics, as did the care managers at Aspen. This was convenient for them, as they were located in the clinic, a situation that also enhanced relations with the primary care physicians. In both organizations, case managers used home health nurses to conduct home visits, although Aspen had its care managers make the home visits for patients who did not meet the Medicare fee-for-service eligibility criteria for home visits. Kaiser Colorado and Aspen also use telephone monitoring.

Caseloads. The four organizations also differed with respect to care manager caseloads. Keystone East planned for care manager caseloads that averaged 130 seniors. At HMO Oregon, caseloads were about 90 seniors per care manager for those seniors who received care management directly from HMO Oregon (that is, other than those enrolled in capitated provider groups). Kaiser Colorado had caseloads between 40 and 50. Aspen care managers tended to have caseloads of approximately 70 seniors, although they were working to reduce caseloads. The differences in these caseloads reflect the structure of the care management programs, as well as such factors as the level of intensity of care management, mostly related to the frequency with which the patient is contacted; whether staff perform other functions such as patient education; and the extent to which care managers are assisted by other staff or rely on home health agency staff.

Aspen’s care management structure was notable because it integrated the efforts of several specialized staff. In particular, there were four programs within the overall care management system:

  1. Acute care coordinators who were based in hospitals and who focused on utilization management and discharge planning. These staff work with the hospital in order to increase efficiency as well as to manage specific patients.

  2. Disease management nurses who provided care management for specific conditions, including frailty as well as chronic obstructive pulmonary disorder, congestive heart failure, and diabetes.

  3. Subacute and long-term care management teams that were led by nurse practitioners and that visited nursing homes regularly to monitor enrollees’ health status and care needs.

  4. Home care staff who provide most of the Medicare-covered home health services to Aspen’s members.

In addition to these staff, there were Integrated Services nurses who were responsible for coordinating the four types of services listed above and for ensuring continuity of care. In particular, Integrated Services nurses worked to ensure smooth handoffs when patients moved from one system to another, or when patients’ needs lay outside the scope of the other programs.

The Legacy Health System “Resource Specialist” Pilot Project. The Legacy Health System, a major provider unit for HMO Oregon, is testing an innovative program at two capitated medical groups (Health First and Adventist) and two independent physician practices. Care management in this program is performed by “resource specialists,” who are not medically trained; rather, they have AB degrees and between 5 and 17 years of social service experience (for example, with Area Agencies on Aging, mental retardation or developmental disability programs, or senior centers). Legacy uses 3.5 full-time-equivalent resource specialists to handle a caseload of 400. About 25 percent of enrollees at the participating clinics are assigned a care manager, a higher ratio than is typical for health plans, and the program includes a focus on people with functional deficits of a milder nature than most health plans would regard as warranting care management.

The resource specialists see patients face-to-face at least quarterly (but often monthly). In addition to coordinating medical care, they emphasize access to social services, family dynamics, and the physical home environment. Importantly, the capitated medical groups have agreed to pay for any off-policy benefits the resource specialist might authorize. Resource specialists work closely with the primary care physicians of enrollees to make sure that the physicians are informed of the enrollees’ situation and of efforts to ameliorate it. No effort is made to discharge patients from care management. The program is being evaluated under a grant from the Robert Wood Johnson Foundation and will be expanded if the research results are favorable.

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