Integrated care for chronic conditions: a randomized care management trial

Health care systems employ community-based solutions to help individuals manage multiple chronic conditions (MCC). Little knowledge exists on how to optimally translate evidence-based integrated care management models into widespread improvements in patient-centered outcomes. This study aimed to compare effectiveness and differential impact of 3 integrated care management delivery methods.

Individual, stratified randomized trial with a 2:2:1 ratio for high-touch (in person), high-tech (remote monitoring), and optimal discharge planning (ODP; telephonic) delivery methods with 12-month follow-up.

The UPMC Health Plan provided care management to adult Medicaid and Medicare-Medicaid beneficiaries with MCC who were recently discharged from an inpatient hospitalization. Primary (90-day readmission, health status, patient activation) and secondary (30-day readmission; functional status; quality of life; care satisfaction; emergent care use; engagement in primary, specialty, and mental health care; gaps in care) outcomes were assessed.

The analytic sample (n = 1387) included Medicaid (79.5%) or dually eligible (20.5%) beneficiaries with MCC (63.0% female, 73.0% White, and 21.6% Black). We found no evidence of a treatment effect on 90-day readmission rates (P = .669). There was a significant improvement over time for health status (P < .0001) but no significant difference by intervention (P = .866). Patient activation showed a significant time-by-treatment interaction (P = .021), with a significant difference (from baseline to 12 months) for the high-touch approach compared with ODP (adjusted difference of 2.69 points; SE = 1.22; P = .028). Participant subgroups (race, age, illness complexity, and comorbid behavioral health conditions) showed no statistically significant differences by interventions or over time on the primary outcomes.

Results demonstrate how health care systems can leverage a variety of impactful, person-centered care management approaches without compromising patient outcomes.