Agency for Healthcare Research and Quality (AHRQ)

Agency for Healthcare Research and Quality (AHRQ)
Effectiveness of Outpatient Case Management for Adults With Medical Illness and Complex Care Needs Prepared for: Agency for Healthcare Research and Quality (AHRQ) Effectiveness of Outpatient Case Management for Adults With Medical Illness and Complex Care Needs This slide set is based on a comparative effectiveness review (CER), Outpatient Case Management for Adults With Medical Illness and Complex Care Needs, Comparative Effectiveness Review No. 99, which was developed by the Oregon Evidence-based Practice Center, Portland, OR, for the Agency for Healthcare Research and Quality under Contract No I and is available online at CERs are comprehensive systematic reviews of the literature that usually compare two or more types of interventions with usual care for the same disease. For this CER, the existing body of evidence on effectiveness of case management programs in improving quality of care, patient-centered outcomes, and resource utilization was reviewed. The literature included in this review was identified from searches of MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects. The databases were searched through August The included studies were predominantly conducted in the United States and Europe and mainly reviewed elderly patients. The number of patients in the included studies ranged from 50 to 18,400. Included studies examined complex care needs, which were defined broadly and were based on health care-resource utilization, patient health status, socioeconomic status, or patient self-management. Studies evaluated the effects of case management on these outcomes when compared with a control (usual care in most cases). Usual care was quite variable across studies; in most cases, however, the comparator was the same milieu of clinical services without a distinct case-management component. Studies in which the primary clinical problem was a psychiatric disorder (other than dementia) and in which case management was used primarily to manage mental illness or a substance abuse disorder were excluded. Studies that provided case management for only short durations (30 days or less) were also excluded. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at

Outline of Material Introduction to case management (CM) programs and the conditions they target Systematic review methods The clinical questions addressed by the comparative effectiveness review Results of studies and evidence-based conclusions about the effectiveness of CM programs for patients with chronic conditions and complex care needs Gaps in knowledge and future research needs What to discuss with patients and their caregivers Outline of Material The material in this presentation covers the results and conclusions from a systematic review entitled Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. It begins with an introduction to case management (CM) programs and the conditions they target. It also covers methods used to plan and execute the systematic review, clinically important questions the review sought to answer, results of the review, evidence-based conclusions about the effectiveness of using CM in patients with chronic illness and complex care needs, gaps in knowledge, and the future research needs uncovered by the systematic review. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Background: Chronic Illness Care and Case Management
Chronic diseases are the leading cause of illness, disability, and death in the United States. For patients with chronic illnesses, health care resources generally are available but may be inaccessible or poorly coordinated. One strategy for improving the effectiveness of care for chronic illnesses is to develop programs that enhance coordination and implementation of care plans. Case management is one such service in which a person, usually a nurse or social worker, coordinates and implements a patient’s care plan. The case manager might work alone or in conjunction with a team of health professionals. The evolution of care models in health care has led to the use of the term “case management” to describe a wide variety of interventions. Background: Chronic Illness Care and Case Management Chronic diseases are the leading cause of illness, disability, and death in the United States. Nearly half of all adults in the United States have at least one chronic illness, and 43 percent of adults covered by both Parts A and B of Medicare have three or more chronic illnesses. For these patients, health care resources generally are available but may be inaccessible or poorly coordinated. Patients require multiple resources, treatments, and providers that are not integrated into a coherent system of care in many health care settings. One strategy for improving the effectiveness and efficiency of care for chronic illnesses is to develop programs that enhance coordination of care and implementation of care plans. Case management is one such supplemental service in which a person, usually a nurse or social worker, takes responsibility for coordinating and implementing a patient’s care plan either alone or in conjunction with a team of health professionals. The evolution of care models in health care has led to the use of the term “case management” to describe a wide variety of interventions. As a result, there is no consensus about the core components of case management. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Background: Functions of a Case Manager
In chronic illness care, while clinical functions are central to the role of a case manager, he or she also performs coordinating functions. Clinical functions of a case manager include: Disease-oriented assessment and monitoring Medication adjustment Health education Self-care instructions The distinct but complementary coordinating functions performed by a case manager include: Helping patients navigate health care systems Connecting patients with community resources Orchestrating multiple facets of health care delivery Assisting with administrative and logistical tasks Background: Functions of a Case Manager Case management tends to be more intensive in time and resources than other chronic illness-management interventions. In the context of chronic illness care, the clinical functions of a case manager are central to his or her role as a case manager; however, a case manager also performs coordinating functions. The clinical functions of a case manager include disease-oriented assessment and monitoring, medication adjustment, health education, and self-care instructions. The coordinating functions performed by a case manager are distinct and complementary to his or her clinical functions. They include helping patients navigate health care systems, connecting them with community resources, orchestrating multiple facets of health care delivery, and assisting with administrative and logistical tasks. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Background: Roles of a Case Manager Within a Health Care Organization
Depending on the health care organization, the case manager can play distinctly different roles: A care provider who helps patients to improve their self-management skills and/or helps caregivers to be more effective in supporting patients A collaborative member of the care delivery team who promotes better communication with providers and advocates for implementation of care plans A patient advocate who evaluates patient needs and works to surmount problems with access to clinical services Background: Roles of a Case Manager Within a Health Care Organization Health care organizations have different strategies with respect to case management programs. Conceptually, a case manager can be seen as an agent of the patient, taking a “whole person” approach to care—rather than a solely clinical or disease-focused one—and serving as a bridge between the patient, the practice team, the health system, and community resources. Depending on the organization, the case manager can play different roles that include: A care provider who supports patients and/or caregivers A collaborative member of the care delivery team A patient advocate who helps patients access clinical and/or community services Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Background: Challenges Related to Evaluating the Effectiveness of Case Management Programs
Individual case management (CM) programs are often customized for the clinical issues of the population they serve. A CM program for homeless people with AIDS has a different mix of activities than a program for patients with dementia and their caregivers. Some CM programs target patients with specific characteristics, while others serve unselected populations with a chronic illness. CM interventions may be intensive and involve frequent contact or may entail only infrequent contact. This variability in CM interventions makes evaluation of the effectiveness of CM programs challenging. Background: Challenges Related to Evaluating the Effectiveness of Case Management Programs Individual case management (CM) programs usually are customized for the clinical problems of the population being served. Thus, a CM program for homeless people with AIDS has a much different mix of activities than a program that serves patients with dementia and their caregivers or one designed to improve the quality of diabetes care. Some CM interventions include primarily coordinating functions, while others focus mainly on clinical activities. Some target patients who have characteristics such as limited social support or physical or mental disability that make them particularly vulnerable to lack of care coordination, while others have a given chronic illness. Some CM interventions are intensive, with multiple face-to-face interactions and home visits, while others entail only infrequent telephone calls. In some CM programs case managers operate independently, while in others they work closely with a patient’s usual care provider or with a multidisciplinary team of health professionals. This variability in CM interventions makes it challenging to evaluate the effectiveness of CM as a discrete entity. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Addressing the Challenges Related to Evaluating the Case Management Programs in This Review
Given the substantial heterogeneity of purposes, approaches, and populations within the broad category of case management (CM) programs, the scope of this review was limited in several ways including: Inclusion of CM programs where case managers had a combination of clinical and coordinating functions Inclusion of CM programs that targeted chronic medical illnesses only Restriction of the review to CM programs that involved a sustained relationship between the case manager and patient Evaluation of patients in outpatient settings only Addressing the Challenges Related to Evaluating the Case Management Programs in This Review The situations in which case management (CM) has been used are numerous and diverse. In recognition of the substantial heterogeneity of purposes, approaches, and populations included within the broad category of CM, the scope of this review was limited in a number of ways. The review aimed to define and identify a subset of CM models representing a sizable category of CM that is common and meaningful for patients and their caregivers. Such an approach allows for a more complete understanding of the evidence regarding the included category of CM. The scope of this review was limited to CM interventions for medical as opposed to psychiatric illnesses. Additionally, the review was restricted to CM that was characterized by an ongoing and sustained relationship between the case manager and patient. Hence, despite promising evidence for certain models of short-term, intensive CM or models that focus on transitional care, such models were not included in this review. The scope of this review was also limited to outpatient settings only. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review (CER) Development
Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others. A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment. The results of these reviews are summarized into Clinician Research Summaries and Consumer Research Summaries for use in decisionmaking and in discussions with patients. The Research Summaries and the full report, with references for included and excluded studies, are available at Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review (CER) Development Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others. A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment. The results of these reviews are summarized into Clinician Research Summaries and Consumer Research Summaries for use in decisionmaking and in discussions with patients. The Research Summaries and the full report, with references for included and excluded studies, are available at Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Clinical Questions Addressed by This Comparative Effectiveness Review (1 of 2)
Key Question 1. In adults with chronic medical illnesses and complex care needs, is case management effective in improving: Patient-centered outcomes, including mortality, quality of life, disease-specific health outcomes, avoidance of nursing home placement, and patient satisfaction with care? Quality of care, as indicated by disease-specific process measures, receipt of recommended health care services, adherence to therapy, missed appointments, patient self-management, and changes in health behavior? Resource utilization, including overall financial cost, hospitalization rates, days in the hospital, emergency department use, and number of clinic visits (including primary care and other provider visits)? Clinical Questions Addressed by This Comparative Effectiveness Review (1 of 2) This comparative effectiveness review attempted to address three key questions. Key Question (KQ) 1 is listed in this slide. KQ 1. In adults with chronic medical illnesses and complex care needs, is case management effective in improving: Patient-centered outcomes, including mortality, quality of life, disease-specific health outcomes, avoidance of nursing home placement, and patient satisfaction with care Quality of care, as indicated by disease-specific process measures, receipt of recommended health care services, adherence to therapy, missed appointments, patient self-management, and changes in health behavior? Resource utilization, including overall financial cost, hospitalization rates, days in the hospital, emergency department use, and number of clinic visits (including primary care and other provider visits)? Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Clinical Questions Addressed by This Comparative Effectiveness Review (2 of 2)
Key Question 2. Does the effectiveness of case management differ according to patient characteristics, including but not limited to: particular medical conditions, number or type of comorbidities, patient age and socioeconomic status, social support, and/or level of formally assessed health risk? Key Question 3. Does the effectiveness of case management differ according to intervention characteristics, including but not limited to practice or health care system setting; case manager experience, training, or skills; case management intensity, duration, and integration with other care providers; and the specific functions performed by case managers? Clinical Questions Addressed by This Comparative Effectiveness Review (2 of 2) This comparative effectiveness review attempted to address three key questions. Key Questions (KQs) 2 and 3 are listed in this slide. KQ 2. Does the effectiveness of case management differ according to patient characteristics, including but not limited to: particular medical conditions, number or type of comorbidities, patient age and socioeconomic status, social support, and/or level of formally assessed health risk? KQ 3. Does the effectiveness of case management differ according to intervention characteristics, including but not limited to practice or health care system setting; case manager experience, training, or skills; case management intensity, duration, and integration with other care providers; and the specific functions performed by case managers? Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Rating the Strength of Evidence From the Comparative Effectiveness Review
The strength of evidence was classified into four broad categories: High Further research is very unlikely to change the confidence in the estimate of effect. Moderate Further research may change the confidence in the estimate of effect and may change the estimate. Low Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate. Insufficient Evidence either is unavailable or does not permit a conclusion. Rating the Strength of Evidence From the Comparative Effectiveness Review Throughout this slide set, strength-of-evidence ratings are assigned to findings of the report. Strength of evidence is typically assigned to reviews of medical interventions or treatments after assessing four domains: risk of bias, consistency, directness, and precision. Available evidence for each comparison-outcome combination was assessed for each of these four domains; the domains were combined qualitatively to develop the strength of evidence for each comparison-outcome combination. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Patient Experience Outcomes
Evidence for the Effectiveness of Case Management Programs That Serve Patients With Multiple Chronic Illnesses (1 of 2) Patient Experience Outcomes CM programs increased the perception of patients that their care was better coordinated. Strength of Evidence: High Clinical Outcomes CM programs did not improve functional status or overall mortality. Evidence for the Effectiveness of Case Management Programs That Serve Patients With Multiple Chronic illnesses (1 of 2) Patient Experience Outcomes There was high-strength evidence that case management programs serving patients with multiple chronic illnesses, when compared with controls, increased the perception of patients that their care was better coordinated. In the Medicare Coordinated Care Demonstration (MCCD) study that evaluated outcomes in 16,301 patients at 12 study sites, quality-of-care outcomes including perception of care coordination and self-care behaviors were assessed. In 8 of the 10 programs in the MCCD trial, participants in the case management group gave higher ratings of the impression that clinicians kept in touch with each other; this difference was statistically significant in 6 programs. In these programs, case management did not appear to have an effect on measures of health behavior, medication adherence, receipt of preventive services, and patient self-care behaviors. Clinical Outcomes There was high-strength evidence that case management programs serving patients with multiple chronic illnesses did not improve functional status or overall mortality when compared with control programs. Five clinical trials and four observational studies examined mortality among patients who received case management. In the MCCD trial, 3-year mortality rates ranged from 10 to 40 percent for the 11 programs for which mortality was reported. Mortality rates in the groups receiving case management were slightly lower in six of these programs and higher in the other five. Five clinical trials and four observational studies examined mortality among patients who received case management. In the MCCD trial, 3-year mortality rates ranged from 10 to 40 percent for the 11 programs for which mortality was reported. Mortality rates in the groups receiving case management were slightly lower in six of these programs and higher in the other five. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Multiple Chronic Illnesses (2 of 2) Resource Utilization Outcomes Case management (CM) programs did not reduce overall hospitalization rates. Strength of Evidence: Moderate CM programs were more effective for preventing hospitalizations when case managers had greater personal contact with patients and physicians. Strength of Evidence: Low CM programs were more effective for reducing hospitalization rates among patients with greater disease burden. CM programs did not reduce Medicare expenditures. Strength of Evidence: High Evidence for the Effectiveness of Case Management Programs That Serve Patients With Multiple Chronic Illnesses (2 of 2) Resource Utilization Outcomes Evidence suggested that case management programs serving patients with multiple chronic illnesses did not reduce overall hospitalization rates. Two programs in the Medicare Coordinated Care Demonstration (MCCD) study found a slightly lower hospitalization rate in the case management programs when compared with control groups. Two other trials found no significant difference in overall hospitalization admissions, readmissions, and nursing home admissions between case management and control groups. Hospital admissions and total inpatient days also did not differ between case management and control groups in four other trials. The strength of evidence for this finding was rated as moderate. There was low-strength evidence that case management programs serving patients with multiple chronic illnesses, when compared with control programs, were more effective for preventing hospitalizations when case managers had greater personal contact with patients and physicians. Analysis of the two programs of the MCCD study that had the greatest reductions in hospitalization rates revealed greater in-person contact between patients and case managers (an average of one in-person contact between the patient and case manager per month with the successful MCCD programs when compared with a median of 0.3 such contacts in the other programs). Additionally, when comparing the successful programs with other programs, the case managers in the successful programs of the MCCD study frequently traveled to primary care sites for direct communication with physicians and also had close contacts with hospitals to provide followup of patients after acute hospitalizations. Four observational studies also found no difference between case management and control groups in hospitalization rates or total inpatient days. There was low-strength evidence that case management programs serving patients with multiple chronic illnesses, when compared with control programs, were more effective for reducing hospitalization rates among patients with greater disease burden. One of the programs included in the MCCD study conducted a risk stratification of its participants at the time of enrollment. For the 30 percent of participants having the highest disease severity, hospitalization rates were 29 percent lower with case management and total expenditures were 20 percent lower. There was low-strength evidence that case management programs serving patients with multiple chronic illnesses, when compared with control programs, were more effective for reducing hospitalization rates among patients with greater disease burden. In this population, case management had minimal effects on the overall costs of care. In the MCCD trial, none of the 12 programs had significantly lower overall Medicare expenditures in the case management group. Total costs also were not significantly different between the case-management and control groups in another U.S. trial. An additional U.S. trial measured only the costs of inpatient hospitalizations; it found no difference between the case-management and control groups. A fair-quality observational study in the United States found higher overall costs in a group receiving case management when compared with a similar group that did not receive case management; the strength of evidence for this finding was rated high. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Evidence for the Effectiveness of Case Management Programs That Serve Frail Elderly Patients
Clinical Outcomes Case management (CM) programs did not affect mortality. Strength of Evidence: Low Resource Utilization CM programs did not reduce nursing home admissions or acute hospitalizations. Evidence for the Effectiveness of Case Management Programs That Serve Frail Elderly Patients Clinical Outcomes There was low-strength evidence that case management programs that serve frail elderly patients did not affect mortality. Two of the good-quality trials measured mortality, and both found no reduction in the intervention group at 1 or 3 years of followup. A fair-quality trial reported a 12-month mortality of 4 percent in the intervention group and 9 percent in the control group; however, this study had a total sample size of only 92, so there was low confidence in this difference. Another fair-quality trial reported no difference in mortality. Resource Utilization Outcomes Case management programs that serve frail elderly patients did not reduce hospitalizations. In a good-quality trial, about one-third of participants in both groups were hospitalized in each of 3 years of followup, with no difference in rates between the case-management and control groups. In the other good-quality trial conducted in the United States, hospitalization rates averaged 37 percent per year, without a significant difference between the case-management and control groups. A fair-quality trial and a fair-quality observational study also found no difference in rates of hospitalization between the case-management and control groups at 6 and 18 months. Trials conducted in other countries arrived at similar conclusions. The strength of evidence for this outcome was rated as low. Case management programs that serve frail elderly patients did not reduce emergency department (ED) admissions. Three trials looked at changes in ED visits. One study found no effect of case management on ED visits in the United States, while a study conducted in Canada found that case management was associated with higher rates of ED visits. In an Italian trial, the case management group had significantly fewer ED visits. A fair-quality observational study conducted in the United States found that ED visit rates were similar in both the case-management and comparison groups. One trial also examined nursing home admissions and found no difference between the case-management and control groups over 12 months; the strength of evidence for this outcome was rated as low. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Patient Experience Outcomes
Evidence for the Effectiveness of Case Management Programs That Serve Patients With Dementia (1 of 2) Patient Experience Outcomes Case management (CM) programs reduced caregiver depression at 2 years and caregiver burden at 12 months. Strength of Evidence: Moderate Quality of Care Outcomes CM programs increased adherence to clinical guidelines for dementia care when focused on those guidelines. Strength of Evidence: Low Resource Utilization Outcomes CM programs did not result in reduction in health care expenditures at 12 months. Evidence for the Effectiveness of Case Management Programs That Serve Patients With Dementia (1 of 2) Patient Experience Outcomes Three good-quality trials assessed depression in caregivers of patients with dementia who were receiving case management programs when compared with control groups. In one trial, caregivers in the case management group reported lower scores on the Neuropsychiatric Inventory (NPI) questionnaire, but this difference did not persist beyond 3 years. In another trial where the case management program was continued for 2 years, caregiver depression was significantly lower in the case management group during the followup period when compared with the control group. While depression scores increased over time in the control group, they decreased over time in the case management group. In a third trial where the case management program was continued for 12 months, NPI scores were lower in the case management arm when compared with the control arm at 12 and at 18 months. Overall, caregiver depression was assessed to be lower in the case management arm when compared with the control arm at 2 years; the strength of evidence for this finding was rated as moderate. There was moderate-strength evidence that case management programs reduced caregiver stress and burden at 12 months. Eight trials, some of which were of good quality and others of fair quality, compared stress or burden in caregivers of patients with dementia who were receiving case management programs when compared with control groups. In one good-quality trial, caregiver stress was found to be significantly lower in the case management group versus the control group; this effect persisted for 4 years. In another good-quality trial where the case management program was continued for 2 years, caregiver burden was lower in the case management group during the followup period when compared with the control group. However, the difference was not statistically significant. A third good-quality trial assessed caregiver stress at 6, 12, and 18 months in patients with dementia who were receiving case management versus a control. The case management program ended at 12 months in this trial. Caregiver stress was better at 12 and 18 months in the case management group when compared with the control group. In two other good-quality trials, caregiver stress was similar in the case-management and control groups. Results of the remaining fair-quality and good-quality trials were mixed. Quality of Care Outcomes One good-quality trial assessed adherence to 23 prespecified dementia care guidelines. At 18 months, adherence to the care guidelines was found to be 64 percent in the case management group versus 33 percent in the control group. No other studies assessed the effect of case management programs on adherence to guidelines. The strength of evidence for this finding was rated as low. Resource Utilization Outcomes Three randomized trials and one observational study evaluated the effect of case management on costs of care for patients with dementia. These studies evaluated costs over 1 to 2 years of followup. A good-quality trial evaluated health care, caregiving, and out-of-pocket costs over 18 months. The monthly cost for case management was modest (mean $118). Total costs (from either a societal or payer perspective) were slightly higher in the control group, but this was not statistically significant. Another good-quality trial also found slightly higher total costs in the control group, but the difference was not statistically significant. The Medicare Alzheimer’s Disease Demonstration and Evaluation (MADDE) trial was a large trial that included an incentive to use home care services by the case management group. It found that case management had little effect on Medicare expenditures. In an observational study, total costs were higher in the case management group, primarily due to higher utilization of clinic visits and acute-care hospitalizations. Overall, there was moderate-strength evidence indicating that case management has little effect on the cost of care in this population. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Dementia (2 of 2) Clinical Outcomes Case management (CM) programs delayed nursing home placement of patients with dementia who have in-home spouse caregivers when program duration was longer than 2 years. Strength of Evidence: Low CM programs did not result in significant delays in nursing home placement if the programs had a duration of 2 years or less. Strength of Evidence: Moderate CM programs did not lower mortality rates. Strength of Evidence: High CM programs did not result in changes in the behavioral symptoms of patients. Evidence for the Effectiveness of Case Management Programs That Serve Patients With Dementia (2 of 2) Clinical Outcomes The was low-strength evidence that case management programs longer than 2 years in duration delayed nursing home placement of patients with dementia. One large good-quality trial with a followup period of 10 years that was conducted in New York City evaluated the effect of case management programs on the ability of patients with dementia to stay at home. Patients who had dementia in this study were required to have in-home caregivers. The case management programs extended over the entire duration of followup (as long as 10 years). By 11 years, about 80 percent of the control-group patients and 70 percent of the intervention-group patients had either died or moved into a nursing home. The authors estimated that the intervention delayed nursing home placement by an average of about 18 months. Six trials, four of which were of good quality, evaluated the effect of case management programs with a duration of 2 years or less on the ability of patients with dementia to stay at home. These trials reported no significant differences in nursing home placement in patients with dementia in the case management groups versus the control groups. The strength of evidence for this finding was rated as moderate. Ten clinical trials and two observational studies reported mortality rates. The timeframes ranged from 1 to 3 years in all but one study, which followed patients for more than 10 years. Deaths often were not recorded after nursing home placement, which could bias the reported rates. The death rates varied considerably in the control groups, ranging from 3 percent at 18 months to 35 percent at 2 years. Across this group of studies, there was no trend toward significantly different mortality rates in the groups that received case management when compared with control groups. The strength of evidence for this finding was rated as high. One good-quality clinical trial with the longest duration of case management and followup found no difference in the frequency of problematic behaviors between the case-management and control groups. The strength of evidence for this finding was rated as moderate. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Congestive Heart Failure (1 of 2) Patient Experience Outcomes Case management (CM) programs increased patient satisfaction. Strength of Evidence: Moderate Quality-of-Care Outcomes CM programs increased patient adherence to recommended disease self-management behaviors. CM programs were more effective in improving patient outcomes when case managers were a part of a multidisciplinary team of health care providers. Strength of Evidence: Low Evidence for the Effectiveness of Case Management Programs That Serve Patients With Congestive Heart Failure (1 of 2) Patient Experience Outcomes Three studies reported the impact of case management on patient satisfaction with care. Two used general measures of patient satisfaction designed or adapted specifically for their studies and found modest but statistically significant improvements in satisfaction in the case management groups when compared with controls. The third study used the Patient Assessment of Chronic Illness Care (PACIC) instrument and found significant improvements in patient ratings with case management. Because of the consistency of positive findings across three studies, the strength of evidence was judged to be moderate that case management improves satisfaction among patients with congestive heart failure (CHF). Quality-of-Care Outcomes Four studies evaluated the impact of case management on indicators of quality of care for CHF. Three examined the use of appropriate pharmacotherapy (e.g., angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers and beta-blockers for patients with systolic heart failure). One study showed improvements in the use of recommended medications with case management, while the other two did not. Three studies examined adherence to self-care recommendations (e.g., low-sodium diet, monitoring weight). All three found that case management improved patients’ adherence to self-management recommendations. Because of the consistency of positive findings across these three studies, the strength of evidence was assessed to be moderate that case management improves adherence to self-care behaviors for CHF. There was low-strength evidence that case management programs were more effective in improving patient outcomes when case managers were integrated with the patient’s usual care providers. Two studies that embedded case managers within teams that included other health professionals (e.g., cardiologist, social worker, dietitian) demonstrated better outcomes across multiple domains in the intervention group when compared with the control group. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Congestive Heart Failure (2 of 2) Clinical Outcomes Case management programs improved quality of life but did not affect mortality. Strength of Evidence: Low Evidence for the Effectiveness of Case Management Programs That Serve Patients With Congestive Heart Failure (2 of 2) Clinical Outcomes There was low-strength evidence that case management programs did not have an effect on mortality. No study found a statistically significant improvement in either all-cause or congestive heart failure (CHF)-related mortality. However, all but one study reported lower mortality rates in the case management group when compared with controls (relative risk, 0.74 to 0.88). The small number of studies—coupled with heterogeneity of the patient populations, case-management interventions, and duration of followup—precluded pooling of data to derive a meaningful estimate of potential mortality reduction with case management. The consistency of relative risk across five studies, however, raises the possibility that case management may provide a survival benefit over usual care for patients with CHF. However, because none of the studies found a statistically significant mortality improvement, the overall impact on improvement appeared to be low. Six studies examined the effect of case management on quality of life (QOL), using a variety of CHF-specific instruments, including the Minnesota Living with Heart Failure Questionnaire, the Kansas City Cardiomyopathy Questionnaire, and the Chronic Heart Failure Questionnaire. Four of these studies also used global measures of functional status that are not specific to CHF: the Medical Outcomes Study SF-36® and the EuroQOL EQ-5D™. Among these six studies, three found significant improvements in CHF-related QOL among patients receiving case management, one of which also found improvements in overall functional status. In the other three studies, QOL scores were similar in the case management and control groups, with minimal evidence of trends toward better QOL in either the case management or control groups. Due to heterogeneity in the results, the authors concluded that the strength of evidence that case management programs improved QOL was low. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Diabetes
Clinical Outcomes Case management (CM) programs improved glucose control. Strength of Evidence: Low CM programs did not improve management of lipids or weight/body mass index. Strength of Evidence: Moderate CM programs were not effective at reducing mortality. Resource Utilization Outcomes CM programs were not effective at reducing hospitalization rates. Evidence for the Effectiveness of Case Management Programs That Serve Patients With Diabetes Clinical Outcomes Eight clinical trials examined the effect of case management programs on glucose control over time as measured by hemoglobin A1c (HbA1c). One good-quality trial found statistically significant improvement in HbA1c to less than 8 percent in the case management group when compared with the usual care group. Two fair-quality trials found statistically significant declines in HbA1c in the case management groups when compared with the usual care group. One trial, also rated as fair in quality, provided information on within-group change in HbA1c over time and identified a possible benefit of case management for HbA1c improvement by this metric. Four trials—three of fair quality and one of good quality—found no significant difference between case management and usual care groups. Three observational studies also examined changes in HbA1c between case management and control groups. Two of these three studies—one rated as good in quality and one rated as fair in quality—found improvement in HbA1c among individuals exposed to case management; whereas, the third study found no significant difference between groups. Taken together, this evidence suggests that a case-management intervention improves glucose control in patients with diabetes but that there is marked heterogeneity of results for this outcome. The strength of evidence for the conclusion of a positive effect on glucose control is low. There was moderate-strength evidence that case management programs did not improve management of lipids or weight/body mass index (BMI). Seven clinical trials and one observational study examined a cholesterol-related outcome—change in total cholesterol, triglyceride levels, low-density lipoprotein (LDL) cholesterol, or high-density lipoprotein (HDL) cholesterol. Of these, most identified no benefit of case management for improving measures of cholesterol control. Because of the consistently negative findings in the other studies, we concluded that there is moderate-strength evidence that case management does not improve lipid measures when compared with usual care. Four trials examined changes in BMI, and none of these identified a benefit of case management. Two trials, one of good quality and one of fair quality, examined change in weight and describe discordant results. In total, five trials found no benefit in BMI/weight adjustment with a case-management intervention while one did find a benefit. There was low-strength evidence that case management programs were not effective at reducing mortality. A clinical trial, rated as fair in quality, examined 5-year mortality in adults with diabetes who were exposed to a case-management intervention. This study did not find a mortality benefit from this case-management intervention after 5 years (hazard ratio for mortality, 1.01; 95-percent confidence interval, 0.82 to 1.24). Resource Utilization Outcomes There was low-strength evidence that case management programs were not effective at reducing hospitalization rates. Two trials examined rates of hospitalization. Despite some design differences between the studies, the results of these two studies for this outcome were both negative (no significant benefit of case management in decreasing rates of hospitalization). This conclusion was rated as having low strength of evidence due to the small number of studies. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Quality-of-Care Outcomes
Evidence for the Effectiveness of Case Management Programs That Serve Patients With Serious Chronic Infections Quality-of-Care Outcomes Case management (CM) programs improved rates of successful treatment for tuberculosis in vulnerable populations who were in short-term programs that emphasized medication adherence. Strength of Evidence: Moderate Clinical Outcomes CM programs did not improve survival among patients with HIV infection. Strength of Evidence: Low Evidence for the Effectiveness of Case Management Programs That Serve Patients With Serious Chronic Infections Quality-of-Care Outcomes The studies of populations with tuberculosis (TB) had case management programs in which the case manager emphasized adherence to drug treatment regimens; these programs generally found higher rates of successful treatment with case management. The study with the best methodological quality was a good-quality interrupted-time-series evaluation. Using a measure of achieving adequate treatment, a successful outcome was achieved for 69 percent of patients during the time period in which conventional directly observed therapy (DOT) was used. This rate increased from 81 to 86 percent in successive time periods in which case management was added to DOT. These rates stayed consistent over four successive 6-month time periods, suggesting that this finding was not due to a time trend unrelated to the use of case management. Higher rates of treatment completion with case management were also observed in two fair-quality clinical trials of patients with TB. A poor-quality observational study compared a population of patients with TB who were receiving case management with a population in a different health system. Treatment success was 87 percent in the case management group and 73 percent in the comparison group. Due to the consistently positive findings in these studies, the authors concluded that the overall strength of evidence is moderate that case management programs emphasizing medication adherence improve rates of successful TB treatment. Clinical Outcomes Two clinical trials of patients with HIV infection included survival as a primary outcome. A fair-quality trial reported a 16-percent mortality rate at 18 months, and a poor-quality clinical trial of patients with AIDS reported a 50-percent mortality rate at 6 months. Neither study found a significant difference in mortality between the case-management and control groups. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Evidence for the Effectiveness of Case Management Programs That Serve Patients With Cancer (1 of 2)
Patient Experience Outcomes Case management (CM) programs improved patient satisfaction with care. Strength of Evidence: Moderate Quality-of-Care Outcomes CM programs were effective in increasing the receipt of appropriate (guideline-recommended) cancer treatment. CM programs were more effective when: The intensity and duration of the intervention was greater The program was integrated with patients’ usual care providers The interventions were structured through preintervention training and care protocols Strength of Evidence: Low Evidence for the Effectiveness of Case Management Programs That Serve Patients With Cancer (1 of 2) Patient Experience Of four studies that analyzed various aspects of patient experience with the care they received, three found case management to be superior to usual care. Two studies found that case management increased patients’ (and caregivers’) satisfaction with care. Another case-management intervention improved breast cancer patients’ sense of having a choice in their treatment. The fourth study showed no difference in perceived unmet needs among patients receiving case management when compared with controls. Due to the consistency of findings across three of these studies, the beneficial effect of case management on patient satisfaction was rated as having moderate strength of evidence. Quality of Care There was moderate-strength evidence that case management programs that served patients with cancer were effective in increasing the receipt of guideline-recommended treatment. Three studies examined the effect of case management on the use of health care services considered to represent high-quality care. All three found that case management improved the use of recommended services. An intervention specifically targeting the use of advanced directives succeeded in increasing the number of completed advanced directives. Other studies demonstrated increased use of breast-conserving surgery (with lymph node dissection and radiation treatment) for women with early stage breast cancer and the early use of radiation as adjunctive therapy for lung cancer. The strength of evidence for this outcome was rated as moderate because of the consistent findings across the studies. There was low-strength evidence that case management programs that served patients with cancer were more effective when the intensity and duration of the intervention was greater, the program was integrated with the patients’ usual care providers, and the interventions were structured through preintervention protocols. The case management programs used across the six included studies were qualitatively analyzed in an attempt to discern the features of successful versus unsuccessful case-management interventions. There were several features that, while not unique to these successful interventions, in the aggregate appeared to distinguish them from less-successful interventions. Specifically, the successful case-management interventions represented more intensive forms of case management, in that they included more contacts and were sustained over a longer period of time than most others. They also explicitly included integration between the case managers and the patients’ usual care providers. Finally, successful case-management interventions appeared to be more structured, as indicated by explicit descriptions of preintervention training for case managers and the use of care protocols to guide case management activities. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Resource Utilization Outcomes
Evidence for the Effectiveness of Case Management Programs That Serve Patients With Cancer (2 of 2) Clinical Outcomes Case management (CM) programs were effective in improving selected cancer-related symptoms and functioning (physical, psychosocial, and emotional) but did not improve overall quality of life or survival. Strength of Evidence: Low Resource Utilization Outcomes CM programs had little effect on overall health care utilization and cost of care. Strength of Evidence: Low Evidence for the Effectiveness of Case Management Programs That Serve Patients With Cancer (2 of 2) Clinical Outcomes There was low-strength evidence that case-management interventions did not improve quality of life (QOL) or survival. Overall QOL and survival were generally not improved by case management in any of the studies that examined those outcomes. There was low-strength evidence that case management programs were effective in improving cancer-related symptoms and functioning. Two studies in which case managers provided symptom management and psychosocial support for patients with lung cancer demonstrated improvements in symptoms and psychosocial or emotional functioning. However, in one of these studies, significant improvements were found in only 3 of 36 prespecified outcome measures, raising the possibility that the improvements resulted by chance rather than as a result of case management. Another study found no differences in symptoms or functional outcomes with case management. In one study, patients receiving case management had a decline in perceived health status over the course of the study, while control patients’ perceived health status steadily improved, even in the presence of greater symptom distress and worse functioning. This seemingly contradictory finding may have indicated, as suggested by the authors, that education and monitoring by case managers instilled more realistic evaluations of health status among homebound patients with lung cancer. Due to the inconsistent findings and changes that were sometimes of small magnitude, the strength of evidence for the effect of case management on these outcomes was rated as low. Resource Utilization Five studies examined the impact of case management on resource utilization (including hospitalizations, emergency department visits, medical visits, and testing) and overall cost of care and found no reduction in overall cost of care. One study found that case management reduced the number of radiographic studies patients underwent but did not affect referrals, hospitalization rates, or the overall cost of care. Other studies similarly demonstrated no difference between case-management groups and controls in utilizing services. In general, the estimated cost of the case-management interventions was small. Thus, the cost of implementing case management had a minimal impact on the overall cost of care, which was driven mainly by the cost of hospitalizations. The overall strength of evidence for the outcome of resource utilization was rated as low. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Resource Utilization Outcomes
Evidence for the Effectiveness of Case Management Programs That Serve Patients With Other Clinical Conditions Resource Utilization Outcomes Case management programs reduced emergency department visits among patients with chronic obstructive pulmonary disease and among homeless people. Strength of Evidence: Low Evidence for the Effectiveness of Case Management Programs That Serve Patients With Other Clinical Conditions There was low-strength evidence that case management programs reduced emergency department visits in the homeless population. A good-quality trial found that compared with the usual care group, homeless patients receiving case management had, on average, about one fewer emergency department (ED) visit per year. However, the homeless case-management group also received housing assistance in addition to case management. There was low-strength evidence that case management programs reduced ED visits among patients with tuberculosis. In a trial of patients with chronic obstructive pulmonary disease (COPD), the group receiving case management had half as many ED visits over 1 year (0.21 visits/year in the case management group vs visits/year in the comparison group). In another trial of patients with COPD, ED visit rates were higher, but visits attributable to exacerbations of pulmonary symptoms were significantly lower in the case management group. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Additional Information
Based on the range of interventions reviewed, the types of patients who potentially could benefit from case management include: Patients with life-threatening chronic diseases—such as congestive heart failure or HIV infection—that can be improved with proper treatment Patients with progressive, debilitating, and often irreversible diseases— such as dementia or multiple chronic diseases in the aged—for which supportive care can enhance independence and quality of life Patients with progressive chronic diseases (e.g., diabetes mellitus) for which self-management can improve health and functioning Patients for whom serious social problems (e.g., homelessness) impair their ability to manage disease Additional Information Based on the entire range of interventions described in the studies included in the review, the types of patients who potentially could benefit from case management generally fell into four categories: Patients with progressive, life-threatening chronic diseases—such as congestive heart failure or HIV infection—that can be improved with proper treatment Patients with progressive, debilitating, and often irreversible diseases—such as dementia or multiple chronic diseases in the aged—for which supportive care can enhance independence and quality of life Patients with progressive chronic diseases (e.g., diabetes mellitus) for which self-management can improve health and functioning Patients for whom serious social problems (e.g., homelessness) impair their ability to manage disease Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Conclusions (1 of 3) Overall, the case-management interventions tested in the reviewed studies were associated with small changes in patient-centered outcomes, quality of care, and health care-resource utilization. Specific findings of this review included: Case management tends to improve patient satisfaction with care for some conditions (congestive heart failure [CHF] and cancer) and increase patient perception of care coordination (for multiple chronic illnesses). Case management improves the quality of care, particularly for illnesses that require complex treatments (CHF, tuberculosis, and cancer). Conclusions (1 of 3) This review found that case management had limited impact on patient-centered outcomes, quality of care, and resource utilization among patients with chronic medical illnesses. Specific findings of this review are that: Case management tends to improve patient satisfaction with care for some conditions (congestive heart failure [CHF] and cancer) and increase patient perception of care coordination (for multiple chronic illnesses). Case management improves the quality of care, particularly for patients with serious illnesses that require complex treatments (cancer, tuberculosis, and CHF). Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Conclusions (2 of 3) Other specific findings of this review included:
For some medical conditions (congestive heart failure and tuberculosis), case management improves patients’ medication adherence and self-management skills. Case-management interventions showed mixed results in improving patients’ quality of life and functional status. For the caregivers of patients with dementia, targeted case-management programs improve levels of stress, burden, and depression. Conclusions (2 of 3) Other specific findings of this review are: For some medical conditions (congestive heart failure [CHF] and tuberculosis), case management improves patients’ medication adherence and self-management skills. Case management improves quality of life in some patient populations (e.g., those with CHF or cancer). For the caregivers of patients with dementia, targeted case-management programs improve levels of stress, burden, and depression. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Conclusions (3 of 3) While low-level evidence suggested that case management can improve some types of health care utilization in patients with multiple chronic illnesses who have greater disease burden and chronic homelessness, the effects of case management on health care-resource utilization and on costs of care are minimal. Low-level evidence also showed that case management produces better outcomes when it is characterized by: Intense programs with greater contact time Longer duration of interventions Integration of programs with patients’ usual care providers Incorporation of training protocols in the interventions Conclusions (3 of 3) Low-level evidence suggested that case management can improve some types of health care utilization in patients with multiple chronic illnesses who have greater disease burden and chronic homelessness. However, the effects of case management on health care-resource utilization and costs of care are minimal. The reviewers also attempted to identify the characteristics of case management programs that were most successful in improving outcomes. Low-level evidence showed that case management produces better outcomes when it is characterized by: Intense programs with greater contact time Longer duration of interventions Integration of programs with patients’ usual care providers Incorporation of training protocols in the interventions Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Gaps in Knowledge (1 of 3) Published trials evaluating the effectiveness of case management (CM) in various patient populations have the following limitations: A lack of effective risk-assessment tools for choosing candidates for CM to determine which patients achieve the greatest benefits from CM A paucity of information on how the effectiveness of CM programs varies with patient characteristics A lack of a uniform, consensus definition for CM A lack of comparisons of CM with other types of interventions Gaps in Knowledge (1 of 3) Trials evaluating the effectiveness of case management in various patient populations were found to have the following limitations: A lack of effective risk-assessment tools for choosing candidates for case management: Research studies have not compared risk-assessment tools or determined which patients achieve the greatest benefits from case management. Risk assessment criteria for choosing candidates for case management could include: Demographics such as age, sex, and ethnicity Living situation and ability to meet basic living needs Access to primary care and other health care services Measures of social support Health care-utilization profiles Clinical risk factors for adverse outcomes A paucity of information on how the effectiveness of case management programs varies with patient characteristics such as disease burden, age, ethnicity, level of social support, and socioeconomic status Lack of specification of case-management components, and comparisons of case management with other types of interventions Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Gaps in Knowledge (2 of 3) Other limitations in the trials evaluating the effectiveness of case management (CM) in various patient populations include: Little or no information about the extent to which CM programs are integrated with the usual source of care Imprecision about the intensity of CM A lack of understanding of the correlation between CM duration and benefits achieved These limitations should be addressed in future studies of CM. Gaps in Knowledge (2 of 3) Other limitations in the trials evaluating the effectiveness of case management in various patient populations include: Little or no information about the extent to which case management programs are integrated with the usual source of care Imprecision about the intensity of case management 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. Lack of understanding of the correlation between case management duration and benefits achieved The duration of the intervention in most trials seems to have been arbitrarily set at 1 to 2 years. The limitations in the trials identified in this review should be addressed in future studies evaluating case management in patients with chronic illnesses and complex care needs. Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

Gaps in Knowledge (3 of 3) Other elements of case management that should be explicitly described in future research include: Experience level of case managers Training received by case managers Specific functions of case managers and the distribution of effort devoted to different activities Use of protocols, guidelines, and information technology Modes of patient contact Average caseload Relationship to other health care providers Gaps in Knowledge (3 of 3) Other features of case management that should be clearly described in future reports evaluating case-management interventions for various disease conditions include: Experience level of case managers Extent of training received by case managers Specific clinical and coordinating functions of case managers and the percentage of time and effort devoted to the different functions Use of prespecified protocols, guidelines, and information-technology support in executing case management programs Modes of contact with patients (clinic visits, home visits, and telephone calls) Average caseload handled by each case manager Extent of interaction between case managers and other health care providers involved in patient care Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

What To Discuss With Your Patients and Their Caregivers (1 of 3)
What case management (CM) is and that the option of involving a case manager in the management of the patient’s medical condition might exist, depending on the patient’s specific medical condition(s) and health care plan Whether the case manager will meet with the patient at his/her home, in your office, or by phone and the frequency of the meetings The potential duration for which the case manager might work with the patient That a case manager will work with the patient’s health care team, although the level of interaction might vary depending on the type of CM program available to the patient What To Discuss With Your Patients and Their Caregivers (1 of 3) Issues you should discuss with your patients with chronic medical illnesses and their caregivers regarding case management include: What case management is and the option of involving a case manager in managing the patient’s medical condition, depending on the patient’s specific medical condition(s) and health care plan Whether the case manager will meet with the patient at his or her home, in your office, or by phone and the frequency of the meetings The potential duration for which the case manager might work with the patient That a case manager will work with the patient’s health care team, although the level of interaction might vary depending on the type of case management program available to the patient Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

That a case manager can be an advocate who evaluates the patient’s needs and works to surmount problems with access to clinical services How case management might affect the patient’s experience of care (patient satisfaction) The available evidence for the effectiveness of case management in improving quality-of-care outcomes (such as receipt of guideline- recommended clinical services, medication adherence, and attending health care appointments) What To Discuss With Your Patients and Their Caregivers (2 of 3) Issues you should discuss with your patients with chronic medical illnesses and their caregivers regarding case management include: That a case manager can be an advocate who evaluates the patient’s needs and works to surmount problems with access to clinical services How case management might affect the patient’s experience of care (patient satisfaction) The available evidence for the effectiveness of case management in improving quality-of-care outcomes (such as receipt of guideline-recommended clinical services, medication adherence, and attending health care appointments) Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

The available evidence for the effectiveness of case management in improving patient-related outcomes (quality of life, ability to stay at home, and health-related outcomes such as mortality and disease symptoms) or caregiver outcomes (such as stress and depression), given the patient’s specific medical condition(s) The available evidence for the effectiveness of case management in improving health care-resource utilization outcomes (such as hospitalization rates, health care costs, and physician and/or emergency department visits) What To Discuss With Your Patients and Their Caregivers (3 of 3) Issues you should discuss with your patients who have a chronic medical illness and their caregivers regarding case management include: The available evidence for the effectiveness of case management in improving patient-related outcomes (quality of life, ability to stay at home, and health-related outcomes such as mortality and disease symptoms) or caregiver outcomes (such as stress and depression), given the patient’s specific medical condition(s) The available evidence for the effectiveness of case management in improving health care-resource utilization outcomes (such as hospitalization rates, health care costs, and physician and/or emergency department visits) Reference Hickam DH, Weiss JW, Guise J-M, et al. Outpatient Case Management for Adults With Medical Illness and Complex Care Needs. Comparative Effectiveness Review No. 99 (Prepared by the Oregon Evidence-based Practice Center under Contract No I). AHRQ Publication No.13-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; January Available at Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99. Available at

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