New York State’s Target Case Management (TCM) program is successful in helping people with HIV stick to their treatment and improves outcomes. But can the program work for other chronic illnesses?
“I think so,” says Mark Brennan-Ing, lead author of a study of the program published last year in PLOS ONE. “Any individual who has complex needs or is having trouble managing their medical and mental health issues really needs this kind of support.”
The comprehensive case management program was created in 1990 by New York state to help people with mental health and substance abuse issues stay engaged in their care. Clients tend to have lower incomes and less education than average. Most are uninsured or are covered by Medicaid or some other public insurance entity. Many are straight and their health is not good—many have multiple health issues—and their social support network is weak.
Brennan-Ing, director for research and evaluation at ACRIA, an AIDS research, education, and advocacy organization with offices in New York, San Francisco, and Washington, D.C., says case managers had to do “a lot of creative things” to keep clients interested in their care. Coordinating and expediting access to care, may be the case manager job description. But they also must build rapport and a relationship with each client and sort of become a surrogate family member.
“It may involve meeting someone at the doctor’s office or actually going to their residence and escorting them there,” he says. “It may involve getting them stable housing or employment or training.”
Facing those challenges the study found that “TCM is able to achieve its goals of improving care engagement and treatment adherence.”
Utilizing data from Amida Care, a not-for-profit managed care plan for people with HIV, Brennan-Ing and his colleagues compared the outcomes of 2,000 people with HIV enrolled in the TCM program to the outcomes of 900 people with HIV who were not in the program. The study covered the period from January 2011 to September 2012.
Along with achieving its goals of keeping HIV clients engaged in their treatment, the TCM program resulted in clients with HIV having significantly higher CD4 counts. By the end of the study, their counts increased, on average, 288.7 cells/mm3 to 503 cells/mm3. A higher CD4 count means a lower viral load, fewer opportunistic infections, and better health for the person with HIV. It also reduces the risk of transmission. The higher CD4 counts for people in the case management program also shows, again, that well-designed nonbiological interventions can have biological benefits.
“It comes down to the bio/psycho/social model of health that basically says it is all tied up together,” Brennan-Ing says. “So your physical health is related to your mental health which is related to your social relationships. So if there is a problem with anyone of those, it affects the other domains.”
Another thing it affects is costs. Over the study period medication and average total per patient care costs for TCM participants rose from $10,857 to $28,590.
“They were filling their prescriptions so that is why the costs go up,” Brennan-Ing says. “If you look at that in the bigger perspective it is money well spent.” In their PLOS ONE study, researchers said preventing new HIV infections will save New York state more than $400,000 in per patient lifetime care costs.
So for people with HIV, these results show that an ounce of case management is worth a pound of cure. By itself, that’s important. Although HIV/AIDS doesn’t get the attention that it once did and the number of new cases diagnosed each year has declined, it remains a grievous health problem. Roughly 1.2 million Americans are living with HIV and almost 40,000 new cases were diagnosed in 2015, the latest year for which figures are available from the CDC.
Brennan-Ing notes that the positive results for people with HIV is an indication that other people with complicated health conditions might benefit from this kind of thorough-going case management.
“The difference with [HIV clients] was the intensiveness of it,” he says. “The level of case management is very reflective of the needs of the client. But any individual who has complex needs and is having trouble managing their medical issues and who may not have social support really needs this kind of support.”