INTEGRATED CASE MANAGEMENT

This issue of the Journal of Ambulatory Care Management is devoted to integrated case management. Integrated case management differs from traditional case management in several ways. First, it allows trained managers to address mental health and chemical dependence problems (mental conditions) in medical patients. Mature models of integrated case management allow trained interdisciplinary managers to assist with both medical and mental conditions without patient handoffs. Second, it targets multidomain health complexity, rather than illness severity and acuity, for manager assistance, recognizing that control of illness is only one factor on the path to overcoming barriers to improvement. Third, integrated case management adopts a longitudinal perspective. Measurable health, not process, outcomes are targeted for improvement, when possible at reduced cost. Although the third difference is emphasized with integrated case management, several traditional case management approaches are also health-outcome and cost reduction oriented.

The Editorial by Lattimer and Kathol on what is meant by the term and the activities of "integrated case management" sets the stage for readers to reflect on its potential to contribute to the Next Generation of health care. Although most articles in this issue do not meet the new tenants of integrated case management by Kathol et al, they do illustrate a need for consistent and agreed upon definitions of care, case, disease, disability, and the many other forms and names of management activities, as the field moves forward. Even in this issue, authors refer to professionals performing activities considered "case management" while using different terms, for example, chronic care management, care coordination, counseling, and assistance by practice nurses.

As importantly, articles differ about the background, training, and activities of those labeled as case managers. Some suggest using management personnel with a high degree of experience and/or training, such as in the articles by McGregor et al and Kathol et al, whereas others suggest that those with less training or without medical backgrounds can perform case management type activity, such as the articles by Williams et al and Kates et al. Three articles in this collection, McGregor et al, Johns et al, and Waxmonsky et al, represent contributions that reflect the rigor with which the background and training for managers must be factored in before the assistance that they give to patients can be expected to improve their outcomes. Each refers to a model of management that has demonstrated clinical value to patients (Katon et al., 2010; Kroenke et al., 2010; Thomas et al., 2006) and, in 2 of them, economic value to the health care system. (Katon et al., 2010; Thomas et al., 2006)

The article by Butler et al provides a backdrop through which other articles provide illumination. They point out through a systematic review of published research trails that the level of integration of "care processes" and "provider roles" does not appear to be associated with study outcomes. These review findings are supported by baseline findings in the Depression Improvement Across Minnesota Offering a New Direction (DIAMOND) project, reported by Williams et al, that is, that the presence of mental health personnel prior to DIAMOND in primary care clinics that screened for depression did not improve depressed patient outcomes (baseline for the compared clinics) compared to usual care. It was not until care management assistance was introduced into primary care clinics that depression outcomes improved. Even then, statistically significant differences between 2 "successful" Mayo clinics remained because lower care management enrollment, follow-up, and staff stability in one clinic led to worse outcomes.

Perhaps the most financially successful "integrated care" program in which mental health capabilities have been introduced into the primary care setting is that described by the Kates et al contribution. In few locations in the United States does the level of funding for mental health services in primary care settings exist such that 84 clinics and over 150 primary care clinicians in one metropolitan area would have onsite mental health support for their patient care. The article provides valuable insight into how to garner funding and to gain local practitioner support for mental health personnel in the primary care setting. Unfortunately, the Hamilton Ontario model used is not one with proven efficacy. Rather, it resembles baseline clinics described by Williams et al.

The articles by Leonard et al and Waxmonsky et al share lessons learned as well as successes they have had from experiences related to the introduction of integrated case management practices as Medicaid health plans in New York and Colorado. Their "feet on the street" and the combination of clinic-based and telephone implementation of care management using case managers trained in interdisciplinary assistance procedures provides insight about grant-supported start-up with largely indigent populations. For both, member (patient) recruitment was a major hurtle and consistent performance of outcome changing care management practices a trial.

Few of the articles in this special issue accomplish the introduction of integrated case management, as defined earlier, into their settings. Rather, they provide lesions from those in the trenches who discuss innovative ways to move the field forward so that the needs of complex patients with comorbid illness can be better met. In reading through the articles in this issue, readers should, however, come to the conclusion that there are key components with which all outcome-oriented integrated case management programs should start:

* A strong patient-manager relationship

* Use of motivational interviewing and patient activation techniques

* Assistance with care coordination and adherence

* Tailoring visit frequency to assistance need, and

* Moving toward concrete goals (treat to target)

Although data supporting the value of integrated case management is early because it is a young field in medicine, it is an area of promise because it could lead to improved health in the patients who use the most health care resources. For this reason, it is an area ripe for comparative effectiveness research (CER) through community, academic, provider, and payor partnerships. But first, those involved in the field must:

1. Adopt consistent and accepted terminology for case management, care management, and integrated case management

2. Define funding opportunities to foster valid CER and other quality studies and then to create clinical payment practices that support programs of value

3. Promote independent, impartial, accurate, and credible evaluation of the economic and clinical outcomes of defined integrated case management programs using methodologies that are transparent, replicable, and standardized

Cheri Lattimer, BSN, RN

President CMI, Executive Director

Case Management Society of America,

Coalition Director, National

Transitions of Care Coalition

Roger Kathol, MD

President, Cartesian Solutions, Inc. and

Adjunct Professor, Departments of Internal

Medicine and Psychiatry,

University of Minnesota

REFERENCES