UCSF

ABSTRACT

This study examines the characteristics and impacts of RN case management on patients' inpatient and Emergency Department (ED) admissions in a 65+ Medicare-enrolled community-dwelling, chronically ill population. Data are from a multi-year randomized controlled trial (RCT) of Medicare Coordinated Care Demonstration (MCCD) program participants in the Carle Clinic healthcare system. This study is a secondary analysis of case management data on 1551 treatment group patients from 2002 through 2005. All patients had at least one of five qualifying chronic health conditions: atrial fibrillation, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease/asthma or diabetes mellitus. Patient characteristics were analyzed to determine association with increased admission risk. The timing and time allocated to RN case management interventions for all participants were analyzed to document case management activities in each of 21 standardized nursing care categories. The association of case management activity type, timing and time with all-cause ED and inpatient admission and readmissions was analyzed to determine which case management activities reduce or increase ED admission or inpatient admission/readmission risk.

Analysis revealed that age, gender, race, urban or rural status, or number of diagnoses were not significantly associated with risk of all-cause inpatient readmission. Of 14 RN Case Managers, 6 were associated with significant reductions in all-cause readmission risk, and one was associated with increased readmission risk. The Identify Needs: Medicare activity, which can include indentifying the need for inpatient or outpatient Medicare-covered health services, was associated with a decrease in inpatient readmission log odds. All Monitor case management activities and Patient-specific Travel were significantly associated with increased ED admission hazard. A final multivariate model identified CHF (OR 2.7, p=.01), as well as Assessment (OR 1.06, p=.03) and Identify Needs (OR .663, p=.06) activities as the strongest predictors of inpatient readmission risk. Patients with 1 inpatient admission versus patients with 2+ admissions received significantly greater amounts of case management time in the categories of Assessment, Identify Needs: Medicare, and Identify Needs: Non- Medicare in most 0-180 day intervals after an index admission. These results indicate that RN case management intervention type, timing and time (amount) were associated with reduced readmission risk in the study population.