Leaders in the field of complex care say health systems need to take a longer view when evaluating results, consider an array of metrics, and see themselves as part of a broader ecosystem of health and social service agencies working with traumatized citizens.
Two recent randomized controlled trials of complex care programs are sparking discussions about how these programs should be designed and what types of metrics should be used to measure their impact. A March 31 panel session included presentations by Camden Coalition and CareMore Health executives about their participation in the studies and next steps, as well as responses by other leaders in the field.
Allison Hamblin, M.S.P.H., president and CEO at the Center for Health Care Strategies (CHCS), a nonprofit health policy resource center, started off the webinar by noting that the work on complex care takes on increasing urgency during the COVID-19 crisis because low-income populations with high levels of comorbidities tend to face the biggest risk from the virus. She noted that the presentations, sponsored by Better Care Playbook, would highlight key takeaways from the recent studies on complex care management programs at the Camden Coalition of Healthcare Providers and CareMore Health.
Leaders from both programs discussed the findings of their studies and the implications for designing, implementing, and evaluating interventions that benefit specific subpopulations. They also detailed continuous improvement efforts to adapt their models and respond to challenges and setbacks.
The Camden Coalition study got lots of media attention when it came out in January. Researchers executed a randomized, controlled trial, to rigorously examine the concept of “healthcare hotspotting”—and found limited longer term impact when narrowly focused on hospital readmission rates. The Coalition’s Camden Core Model uses real-time data on hospital admissions to identify patients who are “superutilizers,” an approach referred to as ‘hotspotting.’ Focusing on patients with chronic conditions and complex needs, and starting with the premise that navigation of the standard system is difficult for these patients, the program uses an intensive, face-to-face care model to engage patients and connect them with appropriate medical care, government benefits, and community services, with the aim of improving their health and reducing unnecessary health care utilization.
As Aaron Truchil, director of strategy and analytics at Camden Coalition, explained, the researchers found that the Camden Core Model had no significant effect on participants’ 180-day readmission rates. But they did see other encouraging findings, such as increased use of social benefits. For instance, they saw an increase in use of SNAP food benefits by 10 percent, and food insecurity has been recognized as a key determinant with this group.
Kelly Craig, M.S.W, chief strategy and information officer, said Camden Coalition continues to iterate on its model. It is working more closely with the jail system on people who also have high rates of healthcare utilization. “The biggest takeaway is that we rely on strong cross-sector partnerships, and we are taking an ecosystem approach.” A few examples are a Housing First program on which Camden Coalition is partnering with five organizations, and a citywide effort to get patients into primary care within seven days of hospital discharge. “We are creating an ecosystem to move toward these goals,” she said. She said Camden Coalition would continue to do evaluations of its work. Questions include what measurements are the right ones beyond traditional return on investment and what nuances need to be considered when measuring impact. Camden Coalition will look to pilot measures of patient experience and patient-reported well-being.
Brian W. Powers, M.D., M.B.A., and Farhad Modarai, D.O., discussed their work on a randomized quality improvement trial conducted at CareMore Health in Memphis, Tenn., that deployed community health workers and other interventions. A total of 253 high-need, high-cost Medicaid patients were randomized to complex care management or usual care. Compared with patients randomized to usual care, patients randomized to complex care management had lower total medical expenses and fewer inpatient admissions, yet there was no significant impact on care center or ED visits. Their study concluded that carefully designed and targeted complex care management programs may be an effective approach to caring for high-need, high-cost Medicaid patients. This study had more exclusion criteria than the Camden Coalition study, so comparing the two is not apples to apples.
Powers noted that patients identified by clinicians as potential participants in the study, in other words people experiencing “rising risk,” saw a greater impact than people identified through claims data algorithms. He said a lesson learned is that they would seek to better harness the intuition of care team members and integrate their referrals. He also said evaluations of such programs should look at cost-effectiveness, not just cost savings.
Modarari said that selecting the right community health workers was key because they serve as engagement specialists. “They function as the worried family member our patients often lack,” he said, adding that building trust with community organizations also helps. “We take a team-based approach, but we have to have an in-depth understanding of community needs and how to navigate the system. Blind referrals are often bureaucratic and cumbersome.”
Following the presentations about the research studies, two other leaders in complex care were asked to respond.
David Labby, M.D., Ph.D., is a health strategy advisor for Health Share of Oregon – one of the 16 coordinated care organizations (CCOs) created as umbrella organizations to oversee physical, mental and dental care in Oregon's Medicaid population. He said the research helped solidify the idea that complex care is not just care management. Many people Health Sare of Oregon works with have faced a lifetime of adversity, including interpersonal violence, substance use disorders and prison. “They are trauma survivors in trauma recovery,” he said. Recovery is not something a case manager does or a year-long program does. It really is much more of a community-based model, of which healthcare is just one part. “Complex care in the populations we serve has to be a community intervention, not a healthcare intervention,” Labby said. “Healthcare has one seat at the table. I appreciate where Camden is going and how Caremore has created partnerships, but how do we take this to the next level? We can’t do this alone and we can’t do it as one sector. These are not short-term interventions. Our programs need to think about them longitudinally. We have to take a longer view and think about systems of care needed to stabilize these populations who have led such challenging lives.” He added that we have to make evaluation of these broader ecosystems part of any study.
Sarah Kaplan-Levenson, M.P.H., M.S.W., vice president of complex care and population health at Maimonides Medical Center in Brooklyn, praised both groups for doing the research in a field where there is a dearth of evidence about what works, saying the ability to be transparent generates conversations and new ideas. She works on healthcare transformation efforts, such as the Brooklyn Health Home, a state-sponsored Medicaid program that provides care management services to socially vulnerable individuals. “We are trying to refine that program from one size fits all to one that is more tailored and person-centered,” she said. Her team wants to make the interventions flexible enough that it looks different to different people. They ask themselves, what kind of duration of intervention does this person need — 90 days or 9 months and who is delivering it? What is the care plan and how does it get implemented? “We want to flex and be nimble and funnel people in who can support their need. From a funding perspective, that requires flexibility. Some people need weekly and some need monthly contact. We are looking at how to make all that sustainable.”
