Jonathan Stokes of the Greater Manchester Primary Care Patient Safety Translational Research Centre presents a systematic review of case management in integrated care.

1. Greater Manchester
Primary Care Patient Safety
Translational Research Centre
Effectiveness of the current dominant approach to integrated
care in the NHS: A systematic review of case management
Jonathan Stokes
This presentation summarises independent research funded by the NIHR Greater Manchester PSTRC.
The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the
Department of Health.

2. Background
Health system challenges
Greater Manchester Primary Care Patient Safety Translational Research Centre
Cost
Complexity
Barnett et al, 2012

3. Background
Integrated Care
Greater Manchester Primary Care Patient Safety Translational Research Centre
“create connectivity, alignment and collaboration” (Kodner & Spreeuwenberg, 2002)
Integrated care examples - Kodner & Spreeuwenberg, 2002
Health system framework - Atun et al, 2013
175 definitions!! (Armitage et al 2009)

4. Integrated care in the English NHS
Greater Manchester Primary Care Patient Safety Translational Research Centre
Effectiveness of this model not been subjected to rigorous
quantitative synthesis across all health system goals
Integrated care emphasis Percentage of CCGs
Multidisciplinary team case management (MDT):
Identification of high risk groups (usually using a risk-stratification tool),
implementation of a structured care plan, and regular monitoring by a
multidisciplinary team based at the primary care level (often involving a social
worker)
81%
Other case management:
Similar to the above model, but the care plan is implemented and regularly
monitored by a single, dedicated case manager (often a practice nurse, or an
intensive case manager)
14%
Joint planning and commissioning:
Integrated care emphasis placed on establishing better links with the Local
Authority and other organisational links e.g. through joined up plans and multi-
agency boards
5%
10% random sample of 211 CCGs (2013)
Publically available documents reviewed – what each branding as integrated care?

5. Methods
Study Selection
Greater Manchester Primary Care Patient Safety Translational Research Centre
Population:
Adults (18+) with long-term conditions
Intervention:
Identifying ‘at-risk’ patients to case
manage
Case management
Primary care/community-based
Comparison:
Usual care or no-case management
Outcomes:
Health – self-assessed health status,
mortality;
Cost – total cost of care, healthcare
utilisation (primary and non-specialist
care and secondary care separately), and;
Satisfaction – patient satisfaction
Study design:
Cochrane EPOC methodology (RCT, nRCT,
CBA, ITS)
Search strategy
Databases
MEDLINE
EMBASE
CINAHL
Cochrane (CENTRAL)
HMIC
CAB Global Health
Blocks of search terms
1. Case management
2. EPOC methodology filter
3. Primary care filter
Exclusions
• Mental health only
• Hospital discharge
planning
• Non-English
language/ grey
literature
Quality
EPOC Risk of bias tool

6. Methods
Data Analysis
Greater Manchester Primary Care Patient Safety Translational Research Centre
Quantitative data extracted
Self-assessed health status
• (Instrumental/) Activities of Daily Living
• Physical/ mental health questionnaires
• Bed days/ restricted activity days
• Quality Adjusted Life Years (QALYs)
Mortality
• Mortality within study period
Total cost of services
• Total cost
• Total insurance expenditure/ reimbursement
Utilisation of primary and non-specialist care
• Primary care physician visits
• Home care visits
• Social worker visits
• Nursing visits
Utilisation of secondary care
• Emergency Department visits
• Hospital admissions/ re-admissions/ days
• Inpatient/outpatient utilisation
• Skilled nursing facility visits/ days
• Ambulance calls
• Specialist visits
Patient satisfaction
• Patient satisfaction questionnaires
• Patient quality of care ratings
Short-term
(0-12 months)
Long-term
(13+ months)
Heterogeneity: I2
Small study bias: Funnel
plots/Egger’s test
Random Effects Model

7. Results
Studies included
Greater Manchester Primary Care Patient Safety Translational Research Centre
• mean age: 75.7 (49.0 to
87.3)
• setting: 64% Low PHC
strength
• patients: 8% Specific
conditions
• intervention: 58% MDT
case management; 33%
Social worker involved
• design: 78% RCT
• follow-up: 6 to 60 months
• quality (9 criteria): 64%
7+; 30% 4-6; 6% 3-

8. Results
Meta-analysis
Greater Manchester Primary Care Patient Safety Translational Research Centre
Health
No. of studies:
Self-assessed health status
14
9
Mortality
12
13

9. Results
Meta-analysis
Greater Manchester Primary Care Patient Safety Translational Research Centre
Cost
No. of studies:
Utilisation of primary care
16
7
Utilisation of secondary care
23
16
Total cost of services
8
5

10. Results
Meta-analysis
Greater Manchester Primary Care Patient Safety Translational Research Centre
Satisfaction
No. of studies:
Patient satisfaction
8
4

11. Discussion
Summary of findings
Greater Manchester Primary Care Patient Safety Translational Research Centre
• Case management has been promoted as a way of reducing health system
pressures
• This review does not provide strong evidence to support this promotion
• total cost of care, and utilisation of secondary care services do not appear
to be significantly affected
• may be significant effect on self-reported health status (short-term: 0.07;
0.00 to 0.14)
• does seem to improve patient satisfaction (short-term: 0.26; 0.16 to
0.36/ long-term: 0.35; 0.04 to 0.66)
Cohen, 1988
• Current results rest on the evidence accumulated from (mostly) RCTs and in
high-income settings. Only assess direct effects
• Evidence from subgroup analyses suggest there may be more effective ways of
delivering the intervention (e.g. by an MDT, with a social worker involved, in a
health system ranked as weak in primary care - see publication)

12. Discussion
Aim of integration
Greater Manchester Primary Care Patient Safety Translational Research Centre
• No evidence that currently integrated care will be the magic bullet hoped to
be:
• Cost/utilisation
• Health benefits
• Satisfaction
• Conflict between NHS ‘patient-centered’ definition (aim!) of integrated care
and what commissioners want it to achieve?
• Satisfaction (patient experience of care) v Cost
• E.g. Fenton et al, 2012 – ‘The cost of satisfaction’
• What do we want integrated care to achieve?... And is it able to?

13. Discussion
Focus on high-risk groups
Greater Manchester Primary Care Patient Safety Translational Research Centre
• Highest risk patients may legitimately require the additional care
• Better identifying these patients can uncover unmet need, and so potentially
increase costly utilisation
• Current risk prediction models primarily based on previous healthcare
utilisation data (so already well-known to services)
Identifying
high-risk
Identifying
preventable
admissions

14. Discussion
Alternative means of integration
Greater Manchester Primary Care Patient Safety Translational Research Centre
Integrated care examples - Kodner & Spreeuwenberg, 2002
Health system framework - Atun et al, 2013

15. Discussion
Organisational integration – e.g. ACOs
Greater Manchester Primary Care Patient Safety Translational Research Centre
• NHS England (Macro-environment)
• GP independently-contracted
• Choice and competition agenda
McLellan et al, 2015
McWilliams et al, 2016
• Multiple providers of IT systems
that don’t link up

16. Discussion
Determinants of health outcomes – potential of models of care
Greater Manchester Primary Care Patient Safety Translational Research Centre
McGovern et al, 2014

17. Discussion
Alternatives to integrated care?
Greater Manchester Primary Care Patient Safety Translational Research Centre
• Addressing current funding gap is most pressing challenge
• Prevention/early intervention?
• Some evidence of ability to reduce demand (Purdy, 2010)…but likely
to take a long time
• Expansion of primary care?
• Some evidence of reduced emergency admissions for minor
conditions (Whittaker et al, 2016)
• Will only realise cost savings if secondary care services
decommissioned
• Workforce problems, e.g. lack of GPs
• Address funding gap directly?
• Health expenditure per capita
• Reverse ‘self-inflicted’ demand increases?
• Austerity choices (e.g. public health, social care budgets, etc.)
• Privatisation
• PFI, Consultancy/Agency staff

18. Acknowledgements
Supervisors:
• Peter Bower
• Kath Checkland
• Søren Rud Kristensen
• Sudeh Cheraghi-Sohi
Other Co-authors:
• Maria Panagioti
• Rahul Alam
Greater Manchester Primary Care Patient Safety Translational Research Centre

19. A partnership between
The NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre
is funded by the National Institute for Health Research (NIHR) and is a partnership between the
University of Manchester and Salford Royal NHS Foundation Trust