Much work has studied care management in primary care to help patients better manage their chronic conditions. The results demonstrate that in research-led interventions, patients improve their clinical and utilization outcomes, however, in real-world implementation, results are mixed. Care management in practices is moving rapidly toward being reimbursable, even though there are significant gaps in understanding regarding what, who, how and to what extent various factors affect implementation and how to overcome problems when they arise. Therefore, we propose a study to investigate these specific aims: 1) To determine the components, processes, functions, and relational interactions that are associated with improved care management outcomes. Primary outcomes include process (practice member and patient participation in care management processes and encounters). Secondary outcomes include patient-specific effects (clinical values and utilization/claims); 2) To determine if practices are involved with quality improvement activities and if those activities are associated with improvement in care management outcomes over a 1-year observation period. The study will include 24 total practices from three primary care physician organizations in two states, all of whom have ongoing care management. To address the aims, we will conduct a triangulation mixed methods analysis including: practice observations and interviews to discover how care management works, who does what, when and how often, how problems occur, as well as how the team communicates, handles issues and makes changes; surveys of practice members regarding interest, knowledge, training and expertise with care management including validated scales of key factors such as culture and learning; surveys and interviews with patients to determine the relationship of personal characteristics with participation in care management, and care management experiences; social network mapping to determine the strength of and relationship among practice members and key others; and shadowing of key practice members to describe the care management processes and interactional patterns. Practices will be additionally examined for evidence of participation in quality improvement activities such as quality improvement training/implementation or introduction of practice facilitators. These will be cataloged using a practice improvement scaled instrument as well as qualitatively described. Using the Consolidated Framework for Implementation Research, and other theoretical models, these data will be analyzed by traditional qualitative analysis, social network analysis, conventional statistical methods, and in a summative fashion using Qualitative Comparative Analysis. Although practice-based care management seems promising, research is needed to inform how to effectively implement it and to maximize the benefit in practices that are struggling. This study will add to the field by providing practical and translatable informatio about what makes care management work and how quality improvement efforts may be related to improvement of this new service in community-based primary care.

R18HS022690

2014-08-01

2017-06-30