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Social needs case management cuts acute care usage



Hospitalizations fell by 11% in patients assigned to integrated social needs case management, a randomized controlled study conducted in California found.

The reduction in acute care use was likely because of the 3% increase in primary care visits with this approach, according to lead study author Mark D. Fleming, PhD, MS, assistant professor of health and social behavior at the University of California, Berkeley. The study was published in Annals of Internal Medicine.

Dr. Mark D. Fleming

The findings provide evidence for the theory that social needs case management can decrease acute care use by facilitating access to primary care, Dr. Fleming said in an interview. “While an increasing number of studies have measured the effects of social needs case management on hospital use, the findings have been inconsistent, with some studies showing a decrease in hospital use and others showing no change.” There was no strong evidence of an effect on acute care.

A 2018 study, however, found that liaising with community care workers substantially reduced hospital days in disadvantaged patients.

Case management, a complex approach linking medical and social needs, can overcome barriers to care by facilitating access to transportation and helping patients navigate the health care system, the authors noted. It can also streamline patient access to insurance coverage and social benefits.

The study

The current data came from a secondary analysis of a randomized encouragement study in Costa County, Calif., during 2017 and 2018. That study allocated adult California Medicaid beneficiaries of diverse race and ethnicity, relatively high social needs, and high risk for acute care use to two arms: social needs case management (n = 21,422) or administrative observation (22,389 weighted). Chronic health issues ranged from arthritis, diabetes, and back conditions to heart or lung disease, and psychological disorders. About 50% in both groups were younger than age 40 and 60% were women.

Case managers assessed patient needs, created a patient-centered care plan, and facilitated community resource referrals, primary care visits, and applications for public benefits.

The professionally diverse managers included public health nurses, social workers, substance misuse counselors, and mental health clinicians, as well as homeless service specialists and community health workers. Case management was offered as in-person or remote telephonic services for 1 year.

While rates of primary care visits were significantly higher in the case management group – incidence rate 1.03 (95% confidence interval [CI],1.00-1.07) – no intergroup differences emerged in visits for specialty care, behavioral health, psychiatric emergency visits, or jail intakes.

Although the analysis could not measure a direct effect of primary care use on hospitalizations, the results suggested it would take 6.6 primary care visits to avert one hospitalization. As a limitation, the outcomes were studied for only 1 year, but further effects of case management on health and service use could take longer to appear.

Commenting on the analysis but not involved in it, Laura Gottlieb, MD, MPH, professor in the department of family and community medicine at the University of California, San Francisco, said a few studies have suggested several pathways through which case management might influence health and health care utilization – and not solely through access to social services.

Dr. Laura Gottlieb, professor in the Department of Family and Community Medicine at University of California, San Francisco Dr. Gottlieb

Dr. Laura Gottlieb

“The current findings underscore that one of those pathways is likely via connection to health care services,” she said.

As to the cost effectiveness of social needs case management given the necessary increase in personnel costs, she added, that it is a matter of society’s priorities. “If we want to achieve equity, we need to invest dollars differently. That is not a hospital-level issue. It is a society-level issue. Hospitals need to be able to stay afloat, so health care policies need to enable them to make different decisions,” she added. Broadly implementing such an approach will obviously take investment, Dr. Gottlieb continued.

“California Medicaid is trying to enable this shift in investments, but it is hard to move existing structures.” She added that more data are needed on the interaction between social services, patient experiences of care, and self-efficacy to understand a wider array of mechanisms through which case management might affect outcomes.

This analysis was supported by the Agency for Healthcare Research and Quality and Contra Costa Health Services. The authors disclosed no relevant conflicts of interest.

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