OBJECTIVE:To measure the impact of point-of-care case management by a team of diverse clinical specialists at a large medical group on 30-day readmissions and associated costs.STUDY DESIGN:An intent-to-treat, historical, baseline cohort comparison design.METHODS:A case management team employed by a managed care organization was integrated into the point of care at 4 medical offices of a medical group to provide services to health plan members who were medically hospitalized. Measures included case management process measures, 30-day readmissions and associated costs, and total savings.RESULTS:Among eligible members, 93% were enrolled in the case management program. In the baseline cohort, 17.60% of members were readmitted within 30 days, compared with 12.08% in the intervention group. Regression models identified case management intervention, prospective risk score, and Medicaid insurance coverage as significantly associated with readmissions and associated costs. Annual savings in 30-day inpatient utilization costs were $1040.74 per member, which considerably exceeded the costs of the program.CONCLUSIONS:Point-of-care case management can be an effective strategy for reducing readmissions and associated costs. Providing services at the point of care allows for greater convenience for members and increased collaboration with physicians. This strategy of a managed care organization collaborating with medical groups and hospitals has the potential to enhance outcomes in accountable care organizations and to support patientcentered medical homes.

INTRODUCTION Inappropriate opioid medication utilization has grown tremendously in recent years. Managed care organizations have the opportunity to identify potential opioid misuse and implement care coordination interventions. METHODS This randomized controlled study evaluated the impact of providing actionable information to prescribers of members who received opioid prescriptions from 3 or more prescribers at 3 or more pharmacies in a 3-month identification period. Impact was assessed through change in number of prescribers, dispensing pharmacies, and filled opioid prescriptions over a 1-year period following identification. RESULTS Members randomly assigned to the intervention group demonstrated greater reductions in the number of prescribers (23.98%), dispensing pharmacies (16.28%), and filled opioid prescriptions (15.25%) over the 1-year period. Regression analyses identified group assignment and the number of opioid prescribers in the 3-month identification period as statistically significant predictors of reductions in the number of prescribers, pharmacies, and filled prescriptions. CONCLUSIONS This intervention provided action-able information to prescribers regarding member opioid utilization, in addition to available managed care resources. It resulted in significantly greater reductions in the number of prescribers, pharmacies, and prescriptions compared with a general information letter notifying prescribers of available managed care resources. Implementation of this intervention has the potential to enhance coordination of care for members potentially at risk for poor health outcomes.

INTRODUCTION As wellness, case, and disease management programs proliferate, health plans must measure their outcomes and potential for return on investment. Here are a few strategies to help with that evaluation. Recent years have witnessed a proliferation of wellness, case, and disease management programs in managed care. Despite their prevalence, few are subjected to the rigorous research designs necessary to determine whether financial goals are achieved. As a result, the effectiveness of these programs in reducing costs remains to be determined (Linden 2006; Mattke 2007). The lack of stringent evaluation of these programs is often attributed to difficulty in identifying a suitable control group (Linden 2006; Linden 2003). Program evaluation in managed care has therefore tended to rely on observational pre-post studies that are subject to selection bias and regression to the mean (Linden 2006). Program evaluators often resort to using a pre-post design with a relatively small percentage of enrolled members, comparing utilization for a specified pre-enrollment period with a similar post-enrollment period, or they compare the results of members enrolled in the program with eligible members who were unable to be enrolled. Each of these designs has critical weaknesses. The pre-post design is highly subject to regression toward the mean. Members are identified for intervention as a function of being a utilization outlier. Regression toward the mean suggests that outliers at one point in time are likely to be closer to the mean at re-measurement, even in the absence of intervention. As a result, reductions in cost and utilization cannot be fully attributed to the intervention. Comparing enrolled members to unenrolled members is subject to selection bias. Members who cannot be enrolled in phoneor mail-based interventions may be fundamentally different from enrolled members. Unenrolled members are unreachable or refuse to accept services. Being unreachable may suggest greater instability in housing or telephone service, or greater financial and psychosocial stressors. Or refusal to accept a free intervention may reflect a low level of motivation to improve health. If enrolled members have fewer financial and psychosocial issues, or are inherently more motivated to improve their health, these differences might explain group outcomes, rather than the intervention. Given the importance of managing health care costs, it is critical that administrators appropriately evaluate outcomes of managed care programs aimed at reducing costs. Measurement strategies are available that avoid regression toward the mean and selection bias, yet they are frequently overlooked. The purpose of this paper is to provide a framework for program evaluators to select the strongest, most feasible design for program evaluation and to provide general strategies to improve program evaluation.

The objective of this study is to determine the reduction in inpatient psychiatric recidivism and costs associated with an intensive case management (ICM) program among high-risk adults with chronic mental health conditions. An intent-to-treat, historical control design was used to examine utilization differences between 306 intervention group (IG) members eligible to receive ICM services and a cohort of 290 baseline group (BG) members over a six-month outcome period. Members were identified retrospectively using identical criteria during one year prior to implementation of the program. The six-month recidivism rate for BG members was 49.67% compared to 22.07% among IG members. Forward stepwise regression results indicated a significant main effect for the ICM intervention on inpatient psychiatric costs. Inpatient psychiatric costs for the six-month outcome period were $4,982.90 lower per member in the IG group. Additional models demonstrated that the ICM intervention was associated with significantly lower inpatient substance abuse costs and psychiatric emergency department costs. There were no statistically significant increases in utilization associated with the ICM intervention. After factoring in program costs, it is estimated that the ICM services contributed to almost $1,500,000 in cost savings over the six-month outcome period. The ICM intervention was associated with significant reductions in inpatient, psychiatric six-month readmission rates and associated costs among adult members who are at elevated risk of inpatient, psychiatric recidivism. The intervention, enrollment process, and measurement strategies can be adapted for use by health plans looking to reduce psychiatric costs.

The purpose of this study is to assess the impact of a group-based program on glucose control for adults with diabetes. Ninety-two adults completed the program aimed at identifying and overcoming barriers to diabetes self-management with the use of behavioral strategies. A comparison group consisted of 275 adults with diabetes not participating in the program matched for age, gender, type of insurance coverage, and initial hemoglobin Alc (HbAlc) result. Members completing the program demonstrated significant improvements in HbAlc results at both the first and second postgroup measurements. Regression analyses identified initial HbAlc result and the interaction of condition and initial HbAlc as significant predictors of improvement in HbAlc. The quality of diabetes care and treatment outcomes can be enhanced with the inclusion of a low-cost, structured program led by a behavioral health professional.

PURPOSE OF THE STUDY:Intensive case management (ICM) holds promise in reducing 30-day inpatient psychiatric recidivism and associated costs. The purpose of this study is to determine the impact of ICM on 30-day inpatient psychiatric recidivism and associated costs among adult health plan members at elevated risk of psychiatric hospitalization.PRIMARY PRACTICE SETTING:Psychiatric settings.METHODOLOGY AND SAMPLE:An intent-to-treat, historical control design was used to examine utilization differences between 305 intervention group members eligible to receive ICM services and a cohort of 347 baseline group members identified retrospectively using identical criteria during a similar 1-year time period before implementation of the ICM program.RESULTS:The 30-day recidivism rate for baseline group members was 29.11% as compared with 8.52% among intervention group members. Logistic regression results indicated a significant main effect for the ICM intervention. Inpatient psychiatric costs for the 30-day outcome period were on $1,528.91 lower per member in the intervention group. Regression results indicated a main effect for the ICM intervention. Program costs were estimated at $41.39 per member.IMPLICATIONS FOR CASE MANAGEMENT PRACTICE:The ICM intervention was associated with significant reductions in inpatient, psychiatric 30-day readmission rates, and associated costs among adult members who are at elevated risk of inpatient, psychiatric recidivism. The intervention, enrollment process, and measurement strategies can be adapted for use by case managers in a variety of different settings.

To address the need to reduce psychiatric emergency-room (ER) recidivism and to promote continuity of care, this study developed a model using administratively obtainable variables to predict psychiatric ER visits in the six months following an index ER visit for a psychiatric condition. Data on member characteristics, preindex psychiatric ER use, index ER information, and postindex utilization for 1,029 adult HMO members visiting the ER for a psychiatric condition were collected and randomly divided in half. A regression model predicting psychiatric ER visits in the six months following the initial psychiatric ER visit was developed in the first data set and tested in the second. In both models, Medicaid insurance coverage, and preindex inpatient admissions for depression or substance abuse were identified as significant predictors of future psychiatric ER utilization. Administratively identifiable variables can be used to identify members at elevated risk of ER recidivism for psychiatric conditions. Through improved identification of risk, case management interventions can be strategically directed to members with the greatest need of services.

Objective:To demonstrate the economic effects of an intervention for members discharged from the emergency department (ED) with anxiety diagnoses.Study Design: Randomized controlled study.Methods: Adults with commercial, Medicare, or Medicaid insurance coverage enrolled in a health maintenance organization and discharged from an ED with anxiety diagnoses were randomly assigned to receive usual care (n = 300) or a stepped-care intervention (n = 307). Psychiatric ED and outpatient visit utilization and cost data identified by claims were collected for 6 months following the initial ED visit.Results: Members assigned to receive the intervention demonstrated significantly fewer ED visits and lower associated facility costs in the 6 months following discharge compared with those assigned to usual care. No significant differences in psychiatric outpatient visit costs were observed. Members receiving usual care made 117 visits to the ED for a psychiatric condition during the follow-up period, for a mean of 0.39 visits per member and a mean facility cost of $118.15 per member, while members receiving case management services made 79 visits to the ED for a psychiatric condition during the follow-up period, for a mean of 0.26 visits per member and a mean facility cost of $70.63 per member. The intervention resulted in a savings of $7.92 in ED costs per member per month for all psychiatric diagnoses during the 6-month study period.Conclusion:The case management-based intervention effectively reduced psychiatric ED recidivism and costs for members discharged from the ED with an anxiety diagnosis, without significantly affecting psychiatric outpatient visit costs.

To develop a model using administrative variables to predict number of days in the hospital for a mental health condition in the year after discharge from a mental health hospitalization. Background, index hospitalization and preindex inpatient, emergency room, and outpatient utilization information were collected for 766 adult members discharged from a mental health hospitalization during a 1-year period. A regression model was developed to predict hospitalized days for a mental health condition in the year after discharge. A regression model was created containing five statistically significant predictors: Medicare insurance coverage, preindex mental health inpatient days, index length of stay, depression diagnosis, and number of mental health outpatient visits with a professional provider. It is possible to predict future mental health inpatient utilization at the time of discharge from a mental health hospitalization using administrative data, thus allowing disease managers to better identify members in greatest need of additional services and interventions.

The integration of behavioral health into the primary care setting provides an opportunity for psychologists to improve care for the treatment of depression. In this study, a pilot program was created integrating psychologists into 4 medical centers. Results indicated a significant improvement in depressive symptoms and health status, and an improvement in overall antidepressant medication adherence. Physicians were highly satisfied with the integrated program. To guide behavioral health specialists considering work in the primary care setting, a description of the program and a discussion of the lessons learned from the project are provided.

Integrating behavioral healthcare into the primary care setting is associated with many benefits; however, plans to integrate care must address several challenges. This article identifies the challenges of integrating behavioral health specialists into primary care and describes strategies used to overcome these challenges.

This article documents the quality improvement process implemented by HIP Health Plan of New York (HIP) for the behavioral health continuity-of-care measure, Follow-Up After Hospitalization for Mental Illness. This Health Plan Employer Data and Information Set (HEDIS) measure identifies the percentage of members who receive psychiatric follow-up care after their hospital discharge. Studies indicate that post-hospitalization psychiatric follow-up care is an effective method for reducing hospital readmissions. HIP's mental health services department pursued a number of improvement initiatives with this HEDIS measure. The development of a case management unit proved the most effective intervention as compliance rates for post-hospitalization after-care visits improved and hospital readmittance rates declined. These findings provide valuable resource information for behavioral health providers throughout the United States.