As noted previously, many health plans are implementing disease management services to target specific chronic illnesses common among high-risk seniors, such as congestive heart failure and diabetes. Disease management techniques use practice guidelines and feedback to manage these conditions (Ellrodt et al. 1997). They are often focused on preventive care that will lower the chances of future hospital admissions. These programs have been widely adopted in and out of managed care (Chen et al. 2000).
However, we did not observe any management programs that were designed specifically to help patients recover from a stroke or hip fracture. This situation may reflect the opinion of physicians in our focus groups that many high-risk seniors need help dealing with a wide range of issues, not a specific disease. As a result, many of the physicians expressed concerns about the specificity of disease management programs, as reflected in the statement of one primary care physician:
I’m skeptical about the disease-specific projects. . . . With elderly people, all the literature is pretty clear that function is the thing to be addressed and not really specific disease states. It’s almost seductive to separate it out, diabetes or heart failure, things that are common diagnoses for people who end up in the ER or however you want to set the marker. . . . I don’t know that the outcomes necessarily justify the kind of disease-specific model.
While specific disease management programs were not found for these two chronic conditions, other disease management approaches might have assisted in the care of these patients. For example, the Kaiser MCO had established a very innovative program to manage patients receiving anticoagulation therapy. Many stroke patients receive anticoagulation therapy, and the management of these patients can be very difficult. Antithrombotic therapy can prevent strokes in carefully selected elderly patients who have chronic nonvalvular atrial fibrillation (Gage et al. 2000). The underuse of antithrombotic therapy in Medicare beneficiaries who have nonvalvular atrial fibrillation is well documented, as are iatrogenic events due to overuse of anticoagulation, and both are associated with serious long-term adverse outcomes. Disease management programs that could have influenced the care of these patients were not limited to the Group MCOs. At Keystone, there were disease management programs for diabetics and congestive heart failure, both of which could be applicable to the postacute care of stroke patients. One physician was particularly enthusiastic about the home visits offered at Keystone East for his high-risk senior patients:
I’ve come to be able to use the HMO to my advantage by having visiting nurses go the patients’ houses and make house calls. Let the HMO pay for the service. Rather than have a doctor go out, you have a nurse visit the patient. They do provide that service. Keystone provides congestive heart failure programs, diabetic programs, physical therapy at the home, and visiting nurses at the home, and we utilize as much of that as possible.
There were also instances where the MCOs had programs that might be useful for treating hip fracture or stroke patients, but those programs did not appear to be widely used. For example, all the MCOs had the opportunity to waive the Medicare requirement for a three- day hospitalization prior to admission to skilled care nursing facilities, and three of the four case study MCOs did this. With stroke patients, this could have been a particularly useful strategy by using the case managers that were co-located in physician’s offices to coordinate the diagnostic evaluation of stroke patients, as well as the admission and followup to skilled nursing facilities. However, we did not find that the MCOs in our case studies frequently took advantage of this alternative approach to the management of stroke patients. In fact, very few patients appeared to be admitted directly to nursing homes, regardless of the case management approach.
Despite the applicability of the broader care management programs to patients with hip fractures and strokes, and of disease management programs representing comorbid illnesses or therapies (such as anticoagulation service), enough of these patients may require extensive resources to warrant more explicit focus. We believe that there may be opportunities to design more specific programs targeted to the chronic management of hip fracture and stroke patients. For example, the rapid, pre-hospital diagnostic evaluation of incident strokes could more efficiently triage these patients (for example, hemorrhagic versus embolic etiologies) into specific protocols that could both reduce costs and improve effectiveness of care. Further, these patients could also be more effectively assigned to rehabilitative interventions based on severity and likelihood of benefit (Bates and Stineman 2000). Disease management programs for hip fracture patients could also ensure that recurrences are potentially mitigated through evidence-based interventions such as home care evaluations for risk of falls (Gill et al. 1999; Close et al. 1999), geriatric assessments (Boult et al. 2001, Ruben et al. 1999), and osteoporosis treatments for reductions of fracture thresholds (Villareal et al. 2001; Neer et al. 2001).