1. Case management for multimorbid patients Nathalie Versnel, MSc. François Schellevis, MD, PhD Giel Nijpels, MD, PhD Caroline Baan, PhD

2. Background  Co-morbid T2DM patients  Participating in several disease specific management programs could lead to uncoordinated care.  Case management in addition to disease management 1 DMDiabetesCareCM All other chronic conditions

3. Background 2  Results literature review – Lower health care costs, – Higher patients‘ perceived quality of care, – Higher satisfaction of patients and caregivers  http://dx.doi.org/10.1016/j.healthpol.2012.06.006 http://dx.doi.org/10.1016/j.healthpol.2012.06.006

4. Aim To investigate the effects of a case management program on quality of care for co-morbid T2DM patients. 3

5. Methods – study design RCT - 2 Practice Nurses (PN) - 230 patients - 8 practices - 12 months  Intervention group (n=115) case management additional to centrally organized managed care (diabetes care)  Control group (n=115) Only centrally organized managed care 4

6. Methods – population Co-morbid T2DM patients Participate in the Diabetes Care System Included comorbid diseases - cancer - chronic ischemic heart disease - chronic obstructive pulmonary disease (COPD) - Depression - osteoarthritis of hip and/or knee - rheumatoid arthritis - stroke 5

7. Methods - intervention  Elements of the case management program - assessing health care needs by Resident Assessment Instrument (RAI) - discussing care plan with the diabetes patient - monthly monitoring - multidisciplinary meetings if needed - coordination of care 6

8. Methods - data collection  Quantitative - Review of the patients’ medical record at the GP. - Postal patient questionnaires at baseline, at 3 and at 12 months. - RAI assessment at baseline and at 12 months.  Qualitative - Semi-structured in-depth interviews for insight in factors favoring and hampering implementation of the program. 7

9. Outcome measures  Primary; difference between the intervention and the control group, after 12 months in the quality of care as perceived by the patients (CQ-Index for GP care and PACIC)  Secondary; - quality of care from the professional perspective (quality indicators) - health status (change in score on the SF-12) - diabetes control (Hba1c) - health care utilization (medication use; number of contacts with care providers) 8

10. Situation at present  First patient started February 2011, last patient July 2012  199 patients  10 trained PN's  11 Primary Care Practices 9

11. Baseline characteristics (n=173) 10 Mean (SD) at baseline Age in years67.8 (11.5) Gender (male)56.1 % Etnicity (Western)97.1 % Native language (Dutch)97.7 % Education level - none/ low - middle - high 35.1% 50.0% 14.9% Number of comorbid illnesses2 (1) Range 1-4 Number of prescibed medication7.3 (3.2) Range 2-17 Health status (SF-12, scale 0-100) - Mental Component Score - Physical Component Score 49.3 (11.2) 34.8 (10.8) Health care utilization (contacts in past 6 months)10 (15) Range 0-87

12. Conclusion 11  Results will be available in 2014  Website study review; http://dx.doi.org/10.1016/j.healthpol.2012.06.006