Best Practices in Care Management for Senior Populations

April 9, 2014

Care Management is a service designed to help patients and their caregivers manage medical conditions more effectively, in order to improve health and reduce the need for hospitalizations and emergency department visits. The concept arose in the past decade from disease management programs of the 1990s, which focused on individual diseases rather than more comprehensive consideration of patients’ needs. Care managers are generally nurses or social workers who work closely with patients and caregivers to assess health risks and needs, collaboratively develop care plans, and coach patients in self-care.[footnote list=”1″ style=”lower-alpha”]All references in this paper correspond to item numbers in the Annotated Bibliography, which details the research on care management.

This seminal report offers a wealth of information about the evidence base for care management, detailing what works in research and practice. The authors considered evidence from randomized controlled trials (RCTs), Medicare demonstration projects, and programs initiated by health systems and private insurers. They concluded that while most care management programs successfully improved quality of care, few achieved cost savings. The authors identified four key elements needed to both save money and improve quality: (1) targeting only high-risk patients, (2) incorporating in-person contact between patients and care managers (including home visits), (3) hiring highly-trained care managers to work with primary care physicians (PCPs) in multidisciplinary teams, and (4) coaching patients in self-care.

The authors concluded that hospital-to-home care transitions programs are most effective at reducing cost and improving quality. Two successful models—Eric Coleman’s Care Transitions Intervention and Mary Naylor’s Transitional Care Model (as described below in items 8 and 9)—demonstrated cost-savings in RCTs and have been adapted to real-world settings by health systems and plans.Care managers strive to ensure close communication between patients and physicians, and among all providers involved in patients’ care.

Health care providers increasingly offer care management, driven in part by reimbursement changes under the Affordable Care Act that sparked provider interest. Health plans are encouraging this trend through reimbursement policies and are moving away from offering care management directly or through vendor-supplied services. This analysis focuses on the question: do care management programs work for senior populations and, if so, what characteristics are shared by the most effective programs?

Key Research Findings

Research shows that care management programs generally improve quality of care, but cost reduction is hard to achieve, especially for patients age 85 and older.6 The research also identifies several key attributes that can increase the likelihood of a program to achieve improved quality and efficiency.

Randomized Controlled Trials

Hospital-to-home care transition programs delivered in health systems are most effective at reducing costs and improving quality.[footnote list=”1″]For additional detail on care transitions, see the CHRT report Care Transitions: Best Practices and Evidence-based Programs. Two proven models are Eric Coleman’s Care Transitions Intervention and Mary Naylor’s Transitional Care Model. In the Coleman program, advanced practice nurses contacted high-risk elderly patients as they were discharged from the hospital, then followed up with the patients by conducting one home visit and three phone calls over a four-week period. In a 2006 study, this program showed a 30 percent reduction in 30-day admissions and a 20 percent reduction in patient costs.

Naylor’s more intensive model provided high-risk, high-cost elderly patients with care management for three months after discharge from the hospital. Advanced practice nurses regularly visited patients’ homes and met with their primary care physicians, and patients could reach care managers by phone seven days a week. As reported in a 2004 study, readmissions dropped by 36 percent and patient costs by 39 percent (nearly $5,000 per patient) within one year.

Care management delivered in other provider settings, including primary care and multispecialty groups, has shown quality improvements but little evidence of cost reduction in RCTs. Evaluations of vendor-supported care management are inconclusive. The Congressional Budget Office determined that the methodologies that vendors used to evaluate their own products were too weak for cost or quality claims to be reliable,1 and the few independent studies of vendor-delivered programs showed limited quality impacts with no evidence of cost reduction.

Demonstration Projects

The Centers for Medicare and Medicaid Services (CMS) runs demonstration projects to test innovative health programs for seniors and measure their impact. Few CMS demonstration projects of care management programs have achieved sufficient cost-savings to offset implementation expenditures. Of the 34 CMS-funded care management demonstration projects since 1999, two raised costs and 31 had no statistically significant impact on reducing costs. There are, however, two programs that did improve quality and produce savings: the Program of All-Inclusive Care for the Elderly (PACE), which began as a CMS demonstration in the 1970s, and a recent demonstration project at Massachusetts General Hospital.

PACE programs generally save money over time but have substantial start-up costs. PACE provides integrated care to elderly, high-risk patients through multidisciplinary teams. Enrollees’ care is managed in adult day care centers, with home care offered as needed. The program dramatically improves patients’ functional status and quality of life, decreases mortality, and reduces hospital and nursing home use. PACE programs have grown slowly, however, largely due to strict program requirements. These requirements include leaving personal physicians in favor of PACE physicians and mandatory attendance at adult day care. Programs that modify the PACE model to increase patient flexibility have not produced the same magnitude of cost savings or quality improvements. For example, in a comparison of a Wisconsin PACE program to a more flexible local competitor based on the PACE model, PACE participants were 68 percent less likely to be hospitalized and 59 percent less likely to be admitted for preventable conditions.

Massachusetts General Hospital ran the only other CMS demonstration that achieved statistically significant cost savings within three years, reducing Medicare expenditures by an estimated 7 to 11 percent by decreasing hospital admissions and emergency department visits. The program enrolled high-risk patients receiving care from the health system and affiliated primary care clinics. Care managers were employed by primary care physicians and managed patients’ care both in person and by phone. The care managers also had access to the health system’s electronic medical records to facilitate communication between providers.

Patient-Centered Medical Homes

Patient-Centered Medical Homes (PCMHs) are the preferred care management delivery model for many health systems, insurers, and state Medicaid agencies. PCMHs are new ways of organizing primary care practices to promote quality of care, coordination between providers, and increased responsiveness to patients’ needs. Care management is a central component of most PCMH demonstration projects. As of 2010, 14 PCMH interventions had demonstrated at least a 10 percent improvement in quality and cost metrics, although some cost measures were not statistically significant. Most successful PCMH programs integrated care managers within practices as part of multidisciplinary teams, aligned financial incentives between providers and payers, and leveraged electronic medical records to increase communication between providers.

Best Practices

Care management programs that successfully reduced costs and improved quality did the following:

  • Provided face-to-face contact between patients and care managers. The frequency of in-person contact varied from an initial appointment in the PCP’s office to regular home visits.
  • Integrated care management within primary care practices. In the best programs, care managers were co-located with primary care physicians or, at minimum, regularly visited the physicians and managed the care of all eligible patients in the practice. In one model, care managers worked in up to three small practices with space set aside for them in each, in order to build strong communication with all physicians.
  • Targeted patient selection. High-risk patients with multiple chronic conditions—generally a subset of the elderly—benefit most and have the greatest potential for cost savings.
  • Stratified services based on patient needs. Stratifying high-risk patients allows more complex patients to receive more intensive services; care managers that manage the most high-risk patients require lower caseloads.
  • Focused on transitions of care from the hospital to other settings. Hospital-to-home transitions are one of the best cost-saving measures, and engage patients when they may be most receptive to behavior change.
  • Coached patients in self-management techniques. Coaching helps patients engage in self-care, manage their medications, and recognize and respond to “red flags” for their conditions.
  • Used electronic medical records. Electronic medical records can be leveraged to assess patients’ health risks, reduce duplication, facilitate communication between providers, and provide feedback to primary care physicians.

While including these elements does not guarantee programs’ success, the research is strong that these features do create the foundation for high-quality, cost-saving care management services.


Care management can help patients and caregivers mitigate the impact of chronic conditions, and reduce the need for expensive health care services such as hospitalizations and emergency department visits. However, while many care management programs have improved quality of care, relatively few have achieved cost savings. This paper outlines best practices that can help providers and health plans invest in care management programs that are designed to promote both quality and efficiency.