Mathematica, Washington, DC, USA.
Mathematica, Princeton, NJ, USA.
J Gen Intern Med. 2021 Oct;36(10):3008-3014. doi: 10.1007/s11606-020-06528-0. Epub 2021 Jan 26.
Longitudinal care management (LCM) for high-risk patients is a cornerstone of primary care models aiming to improve quality and reduce costs.
Describe the extent to which LCM was implemented in the second year of Comprehensive Primary Care Plus (CPC+), and barriers to and facilitators of implementation.
Mixed-methods.
Quantitative: 2715 practices participating in CPC+ in 2018. Qualitative: Interviews with practitioners and staff in 23 representative CPC+ practices.
Across all CPC+ practices, we report median percentages of empaneled patients placed in the highest-risk tiers and, of those, the median percentage receiving LCM. Across 23 CPC+ practices, we report qualitative findings on LCM implementation.
While practices reported benefits of LCM, a small proportion of patients received LCM. Practices placed 2.4% (median) of patients in the highest-risk tier; of these, 30% (median) received LCM. Practices placed 10% (median) of patients in the second-highest-risk tier; of these, 7% (median) received LCM. Interviews revealed LCM uptake across tiers was low because of insufficient care manager staffing. Other challenges included lack of practitioner buy-in to using risk stratification to identify high-risk patients, patients' reluctance to engage in LCM or change behaviors, and limited health information technology functionality for developing, maintaining, and accessing high-risk patients' care plans. Facilitators included embedding care managers within practices and electronic health record functionalities that support LCM.
Despite substantial financial and other supports, and practices' perceived benefits of LCM, insufficient care manager staffing and other barriers have limited its potential in CPC+ to date. To expand LCM's reach, practices need additional care managers, training to overcome barriers to patient engagement, better identification of patients who might benefit from LCM, improved information technology tools for risk stratification and care plans, and more practitioner buy-in to risk stratification.
对高危患者进行纵向护理管理（LCM）是旨在提高质量和降低成本的初级保健模式的基石。
描述在综合初级保健加（CPC+）的第二年中实施 LCM 的程度，以及实施的障碍和促进因素。
混合方法。
定量：2018 年参加 CPC+的 2715 个实践。定性：对 23 个具有代表性的 CPC+实践中的从业者和工作人员进行访谈。
在所有 CPC+实践中，我们报告了被列入最高风险层级的患者的中位数百分比，以及在这些患者中接受 LCM 的中位数百分比。在 23 个 CPC+实践中，我们报告了关于 LCM 实施的定性发现。
尽管实践报告了 LCM 的好处，但只有一小部分患者接受了 LCM。实践将 2.4%（中位数）的患者列入最高风险层级；其中，30%（中位数）接受了 LCM。实践将 10%（中位数）的患者列入第二高风险层级；其中，7%（中位数）接受了 LCM。访谈显示，由于护理经理人员配备不足，各层级的 LCM 采用率较低。其他挑战包括从业者对使用风险分层来识别高危患者的接受度低、患者不愿意参与 LCM 或改变行为，以及用于制定、维护和访问高危患者护理计划的健康信息技术功能有限。促进因素包括将护理经理嵌入实践中，以及支持 LCM 的电子健康记录功能。
尽管有大量的财务和其他支持，以及实践对 LCM 的认知益处，但护理经理人员配备不足和其他障碍限制了其在 CPC+中的潜力。为了扩大 LCM 的覆盖面，实践需要更多的护理经理、克服患者参与障碍的培训、更好地识别可能从 LCM 中受益的患者、改善用于风险分层和护理计划的信息技术工具，以及更多从业者对风险分层的认可。
