The Enhanced Care Management intervention consists of training and coaching doctors to develop care plans and undertake targeted outreach to the subset of patients who are at high risk of experiencing deteriorating health so to increase their utilization of health services. The goal is to extend the use of preventive care, which improves patient health and reduces the need for curative medical services. ECM includes heightened tracking of tests and referrals, follow up after hospital discharges, tracking medication adherence, monitoring between clinic visits, and a focus on achieving clinical quality. It includes four elements: identification of high risk patients through risk stratification, development of care management plans by the primary care physician, proactively linking care providers together, and developing a team approach with patients and their caregivers. ECM is reflective of global primary care reforms that aim to focus the attention of doctors on high-risk groups and improve continuity of care (see Peikes et al, Health Affairs, 2018).
In a pilot of ECM conducted in 2017 with 10 doctors, take up of the intervention was high – pilot providers made 40% more calls to patients with cardiovascular disease (CVD) or one of the “triad” of hypertension, diabetes, and elevated blood lipids; were 11% more likely to have patients on appropriate statin prescriptions; had patients 25% less likely to be hospitalized for CVD-related conditions; and were 11% more likely to follow up within 30 days in the event of an acute CVD incident. However, this pilot was conducted with a purposively selected group of 10 doctors who were expected to be highly motivated early adopters. Even this motivated group expressed that ECM, while generally seen as clinically worthwhile, brought with it additional work in the form of additional time spent on electronic medical records.
Our Estonian counterparts in EHIF and Ministry of Social Affairs (MoSA) expect that take up will be significantly lower when the program is expanded to the general population of primary care physicians. One hypothesis to explain low take-up is that many Estonian doctors are confident in the efficacy of their pre-existing practices. Doctors may be reluctant to adopt ECM because they do not realize that ECM patients, although comprising roughly 6.5% of the patient register, represent a substantially larger share of the burden of disease among their patients – for example, they make up 11.3% of acute admissions. By shifting efforts towards these patients (via the ECM system), they are more closely aligning their efforts to the burden of disease that they face. We will implement 3 treatment arms designed to maximize uptake of ECM by primary care doctors through communicating distinct features of the above ECM rationale. Each aims to shift the appreciation of ECM by doctors along a specific dimension of their work practice.
In the first arm, providers will receive a “big push”-style mentorship introduction to the ECM program over the course of one week from one of the champion providers who participated in the pilot. In the second, providers will have an ongoing, weekly call with the same type of ECM coach which will have a similar overall budget for the implementer per provider. The third arm will receive both treatments. All groups, as well a comparison group, will receive weekly reports on their own performance relative to ECM expectations for patient management.