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Care Management Plus Model

In primary care clinics, Care Management Plus provides information technology systems to facilitate the work of a care manager and the interdisciplinary team to ensure care coordination for older patients with multiple health needs. Drawing from computerized records, a summary worksheet allows the care manager and patient to access the patient's medical history and medications for use in ongoing assessment and adjustments to the care plan when needed. For one common chronic health condition, diabetes, older patients served by Care Management Plus experienced a 24% reduction in hospitalization rates, saving hundreds of thousands of dollars, avoiding likely complications, and sparing their caregivers the stress of having a loved one in the hospital.

Using Technology to Improve Outpatient Care for Older Adults

Intermountain Health Care in Salt Lake City, Utah, has a national reputation for chronic disease care, quality improvement, and innovations in electronic medical records. Building on the pioneering work to integrate technology with care management led by Paul Clayton, PhD, Chief Medical Informatics Officer; Laurie Burns, PT, MS; and Adam Wilcox, PhD, Senior Medical Informaticist, the Foundation awarded Intermountain a 63-month grant of $1,248,373 in 2001 to develop the Care Management Plus model. In a smooth leadership transition, Cherie P. Brunker, MD, Chief of Geriatrics for LDS Hospital and David Dorr, MD, MS, then assistant professor of medicine at the University of Utah, took over direction of the demonstration and brought it to a successful conclusion.

Dr. Dorr, MD, MS
Principal Investigator,
Care Management Plus
Oregon Health & Science University
When patients receive care from several physicians and other health care providers, those clinicians may not communicate effectively with one another and often do not put together comprehensive care plans. Important tests and procedures may not get done and patients may become confused about their medication and treatment regimens. This can result in worse health problems and unnecessary hospitalizations.

“Health care providers tend to struggle with complex chronic illness care; but it can be very rewarding with the right tools in the right environment.” David Dorr, MD, MS
Principal Investigator,
Care Management Plus

To illustrate the problem, Dr. Dorr describes the following typical older patient: Maria Viera is a 75-year old woman with diabetes, high blood pressure, mild congestive heart failure, arthritis, and recently diagnosed dementia. She comes with her husband to see Dr. Smith, her primary care physician (she also sees five other physicians sporadically for her various illnesses), to discuss hip and knee pain, questions about her medicines, dizziness, low blood sugar, and a recent fall. In a typical primary care physician's office, the ability to track these multiple concerns is limited. Likely, Dr. Smith, a busy practitioner, has limited time to address all of Mrs. Viera's complaints or to communicate with her other doctors. Dr. Smith may make recommendations that conflict with instructions by Mrs. Viera's other doctors or she may prescribe medications that interact with drugs she is not aware that Mrs. Viera is taking.

Without a coordinated care plan and follow through, Mrs. Viera's diseases are likely to lead to frequent hospitalizations and emergency visits.

The Care Management Plus model was developed to improve care for patients like Mrs. Viera who have complex illnesses. The model redesigns care in practices of ambulatory care physicians through a team-care approach. It has two main components: the introduction of a care manager (a nurse or social worker) and effective use of an electronic information technology system.

Based on the demonstration's strong results in improved quality of care and financial benefits, the Foundation made a dissemination award of $2,477,509 to Oregon Health & Science University, where Dr. Dorr had relocated as assistant professor of Medical Informatics and Clinical Epidemiology. Colleagues at Utah continue to contribute to the project and Dr. Brunker serves as co-principal investigator for the effort.

With the support of the dissemination grant from the Foundation, interest in and adoption of the Care Management Plus model has exceeded expectations. From the original seven sites, the project expanded to reach 30 sites serving over 8,000 older adult patients in 2007. The developers of the model actively promote Care Management Plus and they continue to receive enthusiastic responses and requests for training in use of the model.
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