By Melinda Young
A case management team can help high-risk patients access social assistance. But to be most effective, they need to help clients access psychosocial support and direct assistance for social needs. A health system’s program reduced inpatient hospitalizations by 11% in a randomized study.1,2
Researchers studied the Community Connect program, implemented by Contra Costa Health Services in California, from 2017 to 2019. They assessed the effect of the intervention on ED visits and inpatient hospital services.
“We asked case managers and patients what they saw as the most important and effective elements of a program for improving health and reducing avoidable acute care use,” says Mark D. Fleming, MS, PhD, lead study author and an assistant professor in the School of Public Health at the University of California, Berkeley.
Three Key Themes
An intervention including the most important mechanisms in helping patients with psychosocial needs effectively reduced acute care use rates among high-risk patients. It reduced ED visits and hospitalizations among a population of Medicaid enrollees in California.
“The analysis looked at what both patients and case managers responded to and found agreement on the most important components for achieving beneficial effects,” Fleming says.
These three key themes emerged:
• Psychosocial work. “This was the work of creating personal, trusting relationships between the case manager and patient as being incredibly important in engaging patients and getting them to engage in healthcare,” Fleming explains. “Many social needs programs often offer referrals, and that may not be sufficient on its own. Trust and rapport are important pieces — you need to develop a relationship so the client trusts the case manager as they interface with the healthcare system.”
Key components of building a trusting relationship, including asking clients to report their care, was important and they felt cared for by the case manager.
Case managers reported they also strived to build trust and provide a caring atmosphere.
“Both case managers and patients talked a lot about the importance of empathy and listening nonjudgmentally,” Fleming says. “Patients really wanted to be able to speak about their situations and feel listened to.”
One key part of psychosocial support was how much high-risk patients with chronic illnesses needed it. “The team helped them work through anxiety and depression when they might not have had access yet to good mental healthcare,” Fleming explains.
Fleming and colleagues studied multidisciplinary teams, which included case managers, public health nurses, social workers, substance use counselors, mental health clinic specialists, homeless service specialists, and community health worker specialists. The multidisciplinary teams tried to match team members’ expertise with patients’ needs.
• System mediation work. Navigating the system is an important part of the team’s approach to helping patients. Case managers helped patients navigate the fragmented landscape and coordinated services across multiple sectors.
“It is distinctive work because it relies on knowledge of multiple resources and knows what services patients might be eligible for,” Fleming says. “It’s covered by the traditional definition of navigation, and we expanded it to suggest it include extensive communication among providers. Case managers provide information across the patient’s care.”
Case managers also coach clients to navigate the system themselves and make sure they make necessary medical appointments. If they face barriers to meeting with healthcare professionals, case managers provide help.
• Addressing social needs. “We decided to call this a separate mechanism because the program made addressing social needs as a separate task with [case management] resources,” Fleming explains. “Case management sees patients’ health conditions as determined by or shaped by their social conditions so they can prioritize and address these as a first step in helping patients. We saw this as a qualitatively distinct aspect of the program that helped lead to its success and avoid acute care and improve health.”
All these themes overlap, but the social needs domain was distinct because it involves screening for social needs and addressing social determinants, such as housing and transportation. “It’s also a specific conceptual lens the case manager brings [to address] the root cause of conditions the patient is facing,” Fleming adds. “Case managers and patients reported to us that when a person has an unmet social need, they cannot be expected to engage in healthcare. It’s a first step in getting health conditions under control.”
This approach to prioritizing tasks underscores the fact social needs are primary in many cases. Exceptions are when the patient’s medical needs are in crisis. “Say someone has severe, unmanaged diabetes, and they’re continually getting hospitalized for that,” Fleming says. “That needs to be addressed right away, even though the person’s housing situation could be a main contributor to their inability to manage the disease.”
Investigators are collecting more evidence about the key ingredients of case management that contribute to a program’s success. Although the outcomes differ depending on the program and population, an evidence-based program about how case management works is important.
“When health systems go to implement a case management program, they can see if it has the essential ingredients to work,” Fleming adds.
Case management might be the result of a fragmented healthcare system in which care must be coordinated between the various siloed levels, but it also is important to patients.
“Many patients need extra support and can benefit from case management,” Fleming says.
REFERENCES
- Fleming MD, Safaeinili N, Knox M, et al. Conceptualizing the effective mechanisms of a social needs case management program shown to reduce hospital use: A qualitative study. BMC Health Serv Res 2022;22:1585.
- Brown DM, Hernandez EA, Levin S, et al. Effect of social needs case management on hospital use among adult Medicaid beneficiaries. Ann Intern Med 2022;175:1109-1117.
A case management team can help high-risk patients access social assistance. But to be most effective, they need to help clients access psychosocial support and direct assistance for social needs. A health system’s program reduced inpatient hospitalizations by 11% in a randomized study.
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