The effects of a school-based case management program on adolescent high-risk behavior: The enrichment support services program

BACKGROUND Impactability modeling promises to help solve the nationwide crisis in caring for high-need high-cost patients by matching specific case management programs with patients using a “benefit” or “impactability” score, but there are limitations in tailoring each model to a specific program and population. OBJECTIVE We evaluated the impact on Medicare ACO savings from developing a benefit score for patients enrolled in an historic case management program, then prospectively implementing the score and evaluating the results in a new case management program. METHODS We conducted a longitudinal cohort study of 76,140 patients in a Medicare ACO with multiple before-and-after measures of the outcome using linked electronic health records and Medicare claims data from 2012 to 2019. There were 489 patients in the historic case management program and 1,550 matched comparison patients; 830 patients in the new program with 2,368 matched comparisons. The historic program targeted high-risk patients and assigned a centrally-located registered nurse and social worker to each patient. The new program targets high- and moderate-risk patients and assigns a nurse physically located in a primary care clinic. Our primary outcomes were any unplanned hospital events (admissions, observation stays, and ED visits), count of event-days, and Medicare payments. RESULTS In the historic program, as expected, high-benefit patients enrolled in case management had fewer events, fewer event-days, and an average $1.15 million reduction in Medicare payments per 100 patients over the subsequent year when compared to matched comparisons. For the new program, high-benefit high-risk patients enrolled in case management had fewer events, while high-benefit moderate-risk patients enrolled in case management did not differ from matched comparisons. CONCLUSIONS Although there was evidence that a benefit score could be extended to a new case management program for similar (i.e., high-risk) patients, there was no evidence that it could be extended to a moderate-risk population. Extending a score to a new program and population should include evaluation of program outcomes within key subgroups. With the increased attention to value-based care, policy makers and measure developers should consider ways to incorporate impactability modeling into program design and evaluation. CLINICALTRIAL N/A

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HIV testing and ART initiation among partners, family members, and high-risk associates of index clients participating in the CommLink linkage case management program, Eswatini, 2016–2018

PLoS ONE ◽

10.1371/journal.pone.0261605 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0261605

Author(s):

Daniel Williams ◽

Duncan MacKellar ◽

Makhosazana Dlamini ◽

Johnita Byrd ◽

Lenhle Dube ◽

...

Keyword(s):

High Risk ◽

Case Management ◽

Hiv Testing ◽

Phase Ii ◽

Family Members ◽

Management Program ◽

Hiv Positive ◽

Case Management Program ◽

Art Initiation ◽

Biological Children

To help diagnose and initiate antiretroviral therapy (ART) for ≥95% of all persons living with HIV (PLHIV), the World Health Organization (WHO) recommends offering HIV testing to biological children, and sexual and needle-sharing partners of all PLHIV (index-client testing, ICT). Many index clients, however, do not identify or have contactable partners, and often substantially fewer than 95% of HIV-positive partners initiate ART soon after index testing. To help improve early HIV diagnosis and ART initiation in Eswatini (formerly Swaziland), we implemented a community-based HIV testing and peer-delivered, linkage case management program (CommLink) that provided ICT as part of a comprehensive package of WHO recommended linkage services. CommLink was implemented June 2015 –March 2017 (Phase I), and April 2017 –September 2018 (Phase II). In addition to biological children and partners, HIV testing was offered to adult family members (Phases I and II) and high-risk associates including friends and acquaintances (Phase II) of CommLink index clients. Compared with Phase I, in Phase II proportionally more CommLink clients disclosed their HIV-infection status to a partner or family member [94% (562/598) vs. 75% (486/652)], and had ≥1 partners, family members, or high-risk associates (contacts) tested through CommLink [41% (245/598) vs. 18% (117/652)]. Of 537 contacts tested, 253 (47%) were HIV-positive and not currently in HIV care, including 17% (17/100) of family members aged <15 years, 42% (78/187) of non-partner family members aged ≥15 years, 60% (73/121) of sexual partners, and 66% (85/129) of high-risk associates. Among 210 HIV-positive contacts aged ≥15 years who participated in CommLink, nearly all received recommended linkage services including treatment navigation (95%), weekly telephone follow-up (93%), and ≥3 counseling sessions (94%); peer counselors resolved 76% (306/404) of identified barriers to care (e.g., perceived wellness); and 200 (95%) initiated ART at a healthcare facility, of whom 196 (98%) received at least one antiretroviral refill before case-management services ended. To help countries achieve ≥90% ART coverage among all PLHIV, expanding ICT for adult family members and high-risk associates of index clients, and providing peer-delivered linkage case management for all identified PLHIV, should be considered.

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