Case management for multimorbid patients
Nathalie Versnel, MSc.
François Schellevis, MD, PhD
Giel Nijpels, MD, PhD
Caroline Baan, PhD
Background
 Co-morbid T2DM patients
 Participating in several disease specific management programs
could lead to uncoordinated care.
 Case management in addition to disease management
DM
Diabetes
Care
CM
All other
chronic
conditions
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Background
 Results literature review
– Lower health care costs,
– Higher patients‘ perceived quality of care,
– Higher satisfaction of patients and caregivers
 http://dx.doi.org/10.1016/j.healthpol.2012.06.006
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Aim
To investigate the effects of a case
management program on quality of
care for co-morbid T2DM patients.
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Methods – study design

RCT
- 2 Practice Nurses (PN)
- 230 patients
- 8 practices
- 12 months
 Intervention group (n=115)
case management additional to centrally organized
managed care (diabetes care)
 Control group (n=115)
Only centrally organized managed care
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Methods – population

Co-morbid T2DM patients

Participate in the Diabetes Care System

Included comorbid diseases
- cancer
- chronic ischemic heart disease
- chronic obstructive pulmonary disease (COPD)
- Depression
- osteoarthritis of hip and/or knee
- rheumatoid arthritis
- stroke
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Methods - intervention
 Elements of the case management program
- assessing health care needs by Resident Assessment
Instrument (RAI)
- discussing care plan with the diabetes patient
- monthly monitoring
- multidisciplinary meetings if needed
- coordination of care
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Methods - data collection
 Quantitative
- Review of the patients’ medical record at the GP.
- Postal patient questionnaires at baseline, at 3 and at 12
months.
- RAI assessment at baseline and at 12 months.
 Qualitative
- Semi-structured in-depth interviews for insight in factors
favoring and hampering implementation of the program.
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Outcome measures
 Primary;
difference between the intervention and the control group,
after 12 months in the quality of care as perceived by the
patients (CQ-Index for GP care and PACIC)
 Secondary;
- quality of care from the professional perspective (quality
indicators)
- health status (change in score on the SF-12)
- diabetes control (Hba1c)
- health care utilization (medication use; number of
contacts with care providers)
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Situation at present
 First patient started February 2011, last patient July 2012
 199 patients
 10 trained PN's
 11 Primary Care Practices
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Baseline characteristics (n=173)
Mean (SD) at baseline
Age in years
67.8 (11.5)
Gender (male)
56.1 %
Etnicity (Western)
97.1 %
Native language (Dutch)
97.7 %
Education level
- none/ low
- middle
- high
35.1%
50.0%
14.9%
Number of comorbid illnesses
2 (1) Range 1-4
Number of prescibed medication
7.3 (3.2) Range 2-17
Health status (SF-12, scale 0-100)
- Mental Component Score
- Physical Component Score
49.3 (11.2)
34.8 (10.8)
Health care utilization (contacts in past 6 months)
10 (15) Range 0-87
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Conclusion
 Results will be available in 2014
 Website study review;
http://dx.doi.org/10.1016/j.healthpol.2012.06.006
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