Can care management enhance integration of primary and specialty care?

Dietrich et al report a randomised controlled trial in which community practices implemented enhanced care for depressive illness.1 The programme was a quality improvement initiative of the participating healthcare organisations, not a stand alone intervention provided by the researchers. Key elements included telephone follow up of patients by a care manager, support of the care manager and the primary care clinician by a psychiatrist, and increased attention to patient education and goal setting by the primary care clinician. The magnitude of benefits was comparable to those of some previous effectiveness trials in which interventions were delivered by researchers.2 On completion, the organisational changes were extended to additional practices in the participating organisations.

Evidence that depression outcomes can be improved through systematic changes in delivery of care is now compelling.2 3 This study shows that community practices are able to implement and sustain improvements when offered a standardised care management programme and adequate support. Other chronic conditions that would benefit from such programmes include congestive heart failure, diabetes, and asthma.

As healthcare organisations consider implementing care management programmes, this study highlights three key points: the programme was standardised, but implementation was customised to each setting by the organisations; the care manager—a centralised resource not located in the primary care clinic—managed patients in collaboration with the clinician, who retained overall responsibility for patient care; a psychiatrist supervised the care manager, provided guidance to the clinician through the care manager, and advised the clinician directly as needed.

As a package, the introduction of a care management programme facilitated key changes in how patients, allied health professionals, clinicians, and specialists worked together to improve patient outcomes. By serving as a communication link, care managers can potentially bridge the ever widening gap in coordination of care between clinicians and specialists.4 In an era when technological progress has accelerated medical specialisation, ageing populations with multiple chronic conditions need integration of health care more than ever. Primary care clinicians will either embrace new ways of integrating care for their patients or continue to struggle with the onslaught of too many patients, seen in too little time, with seemingly disparate and disconnected needs. By enhancing communication and follow up, care managers may play a vital part in enhancing continuity of care, efficiently integrating the roles of the specialist and the primary care clinician.

Whether and how care management will be implemented on a mass basis is not settled. Should each major disease have its own care manager? Programmes of proved effectiveness have typically targeted individual chronic conditions, but this may not be the best path to integrating care for patients with multiple chronic conditions. It is heartening to learn that a centralised care management programme for depression, linked to primary care, could be successfully implemented and sustained in diverse community practices, but whether and how care management will be integrated into routine practice for the range of conditions that might benefit from enhanced follow up and coordination of care remains an open and critically important issue.