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Hickam DH, Weiss JW, Guise JM, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Jan. (Comparative Effectiveness Reviews, No. 99.)

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Outpatient Case Management for Adults With Medical Illness and Complex Care Needs [Internet].

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Future Research

The existing evidence base includes a large number of randomized trials comparing case management (CM) with “usual care.” While the components of usual care were quite variable across studies, in some cases (particularly the Medicare Coordinated Care Demonstration [MCCD] trial)32 the studies had large sample sizes and good overall methodological quality, and there is unlikely to be a high yield in continuing to repeat such studies. Instead, future clinical research needs to address the gaps in the current evidence base. These gaps include:

  • Lack of effective risk assessment tools for choosing candidates for CM. Some published trials29 have used existing tools but no studies have compared tools or rigorously examined patient subgroups to learn which patients achieve the greatest benefits from CM. The factors included in better risk profiles could include:
    • Demographics including age, gender, and ethnicity
    • Living situation and ability to meet basic living needs
    • Access to primary care and other health care services
    • Social support
    • Health care utilization profiles
    • Clinical risk factors for adverse outcomes.
  • Lack of understanding of the length of time to continue CM. Nearly all trials have set seemingly arbitrary durations of the intervention (often 1 to 2 years). It is not known when the benefits of the intervention have been achieved. Some of the negative results may be due to the CM being too short. This is particularly important if developing an effective long-term relationship between the patient and case manager affects the program's success.
  • Imprecision about the intensity of CM. Existing trials have infrequently examined whether patient outcomes are influenced by the frequency of case manager contact, the length and content of the contacts, and the approach to followup of problems.

Other examples of CM elements that should be explicitly described in future research include:

  • Training received by case managers
  • Case manager experience
  • Specific functions of case managers and the distribution of effort devoted to different activities
  • Modes of contact (clinic visits, home visits, telephone calls)
  • Average caseload
  • Relationship to other health care providers
  • Use of protocols, guidelines, and information technology.

CM typically involves case managers providing both direct clinical support and coordination for patients, as well as education and empowerment to enable patients to better manage their own conditions and coordinate their own care. Better specification of intervention components and population characteristics would contribute to greater understanding of when interventions should emphasize direct support compared with patient education.

Many CM interventions employed more than one case manager, but few studies examined the effectiveness of CM delivered by different case managers. CM is a human intervention, and the effectiveness of CM may vary substantially according to the skills, experience, and personality of the person delivering the intervention. Understanding how much variability there is from one case manager to another would provide valuable information about the degree to which CM can be standardized and the importance of choosing individuals to implement CM.

As discussed above, future research should compare CM with other interventions designed to achieve similar outcomes, particularly interventions that are less intensive or more narrowly focused and may thereby achieve desired outcomes more efficiently. Such studies would help determine in which situations CM adds value over potentially less costly interventions.

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