The Impact of Comprehensive Case Management on HIV Client Outcomes

Brennan-Ing M, Seidel L, Rodgers L, Ernst J, Wirth D, Tietz D, Morretti A, Karpiak SE
Source: PLoS One
Publication Year: 2016
Patient Need Addressed: Behavioral health, Chronic Conditions, Long-term services and supports
Population Focus: Medicaid eligible
Demographic Group: Adult
Intervention Type: Staff design and care management
Study Design: Pre-post with Comparison Group
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/26849561
Abstract

In 1990, New York State instituted Comprehensive Medicaid Case Management, also known as Target Case Management (TCM), for people dealing with multiple comorbid conditions, including HIV. The goal of TCM is to assist clients in navigating the healthcare system to increase care engagement and treatment adherence for individuals with complex needs. HIV-positive individuals engaged in care are more likely to be virally suppressed, improving clinical outcomes and decreasing chances of HIV transmission. The purpose of this study was to understand the impact of TCM management on outcomes for people with HIV. Data were obtained from Amida Care, which operates not-for-profit managed care Medicaid and Medicare Special Needs Plans (SNPs) for HIV clients. Changes in clinical, cost, as well as medical and pharmacy utilization data among TCM clients were examined between January 2011 through September 2012 from the start of case management enrollment through the end of the study period (i.e., up to 6 months after disenrollment). Additionally, CD4 counts were compared between Amida Care TCM clients and non-TCM clients. Notable findings include increased CD4 counts for TCM clients over the one-year study period, achieving parity with non-TCM clients (i.e., Mean CD4 count > 500). When looking exclusively at TCM clients, there were increases in medication costs over time, which were concomitant with increased care engagement. Current findings demonstrate that TCM is able to achieve its goals of improving care engagement and treatment adherence. Subsequent policy changes resulting from the Affordable Care Act and the New York State Medicaid Redesign have made the Health Home the administrator of TCM services. Government entities charged with securing and managing TCM and care coordination for people with HIV should provide thoughtful and reasonable guidance and oversight in order to maintain optimal clinical outcomes for TCM clients and reduce the transmission of HIV.

Insights Results

Overview of article

  • Target Case Management (TCM) improves clients’ engagement with care and treatment adherence as evidenced by significant increases in actuarial risk scores (i.e., a proxy for increased service utilization), medication costs, and total costs. This study sought to examine the effectiveness of TCM services for people with HIV in New York State with regard to increased care engagement and improved treatment adherence by analyzing changes in clinical, cost, and utilization data among TCM clients over the course of their case management enrollment
  • Demographic characteristics of the sample were restricted to age and gender, which did not allow analysis of how race/ethnicity and other factors may have been related to case management client outcomes

Methods of article

  • Data were obtained from Amida Care, which operates non-profit managed care Medicaid and Medicare Special Needs Plans (SNPs) for HIV clients. Changes in clinical, cost, as well as medical and pharmacy utilization data among TCM clients were examined between January 2011 through September 2012 from the start of case management enrollment through the end of the study period (e.g., up to 6 months after disenrollment). Additionally, CD4 counts were compared between Amida Care TCM clients and non-TCM clients

Results

  • Initial data show that for New York State Medicaid patients without prior case management, Health Home enrollment is associated with decreased emergency room visits and hospital admissions, and increased primary care visits. However, no data are available to assess the impact Health Home enrollment on clients who had been receiving TCM, so it is difficult to evaluate the success of this model at present
  • Since many states do not invest in the full range of services necessary to achieve better health outcomes, flexible federal funding streams such as Ryan White will be critical to not only achieving the National HIV/AIDS Strategy (NHAS), but to redesigning healthcare systems to insure better health outcomes and mitigate expenditures

Key takeaways/implications

  • Sensible and stakeholder-driven Medicaid redesign and the implementation of Health Home model represents an important opportunity to remake a significant part of the health and human services delivery system serving people with HIV
  • This effort could serve as a model to other states seeking to reduce their Medicaid and other healthcare expenditures
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