Key result
Care managers identify primary care follow-up, service coordination, and relationship-building as key drivers of patient outcomes.
Why the study?
The contributions of care management as perceived by care managers coordinating care for chronic and surgical patients were not well characterized.
Different care management settings prioritize different activities for improving patient outcomes, suggesting interventions should be tailored to specific medical conditions and settings.
Care managers’ perceived contributions in HF/COPD coordination remain hypothesis-generating; leaves open measurable impact on patient or clinician outcomes.
OBJECTIVES: The aim of this study is to assess the contributions of care management as perceived by care managers themselves. STUDY DESIGN: Focus groups and interviews with care managers who coordinate care for chronic obstructive pulmonary disease and congestive heart failure patients, as well as patients undergoing major surgery. METHODS: We collected data in focus groups and interviews with 12 care managers working in the Keystone Beacon Community project, including 5 care managers working in hospitals, 2 employed in outpatient clinics and 4 telephoning discharged patients from a Transitions of Care (TOC) call center. RESULTS: Inpatient care managers believe that (1) ensuring primary care provider follow-up, (2) coordinating appropriate services, (3) providing patient education, and (4) ensuring accurate medication reconciliation have the greatest impact on patient clinical outcomes. In contrast, outpatient and TOC care managers believe that (1) teaching patients the signs and symptoms of acute exacerbations and (2) building effective relationships with patients improve patient outcomes most. Some care management activities were perceived to have greater impact on patients with certain conditions (e.g., outpatient and TOC care managers saw effective relationships as having more impact on patients with COPD). All care managers believed that relationships with patients have the greatest impact on patient satisfaction, while the support they provide clinicians has the greatest impact on clinician satisfaction. CONCLUSIONS: These findings may improve best practice for care managers by focusing interventions on the most effective activities for patients with specific medical conditions.
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Carayon et al. (2015) studied Chronic obstructive pulmonary disease, congestive heart failure, and major surgery (n=12). Care management activities was evaluated on Perceived impact on patient clinical outcomes and satisfaction. In a qualitative study of 12 care managers, ensuring primary care follow-up, coordinating services, and building effective relationships were perceived to have the greatest impact on patient outcomes.
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