TY - JOUR
AU - K. Williams
AU - J. N. Kogan
AU - S. Markwardt
AU - C. Kang
AU - D. Landsittel
AU - E. Beckjord
AU - J. F. Karp
AU - D. Swayze
A1 - 
AB - OBJECTIVES: Health care systems employ community-based solutions to help individuals manage multiple chronic conditions (MCC). Little knowledge exists on how to optimally translate evidence-based integrated care management models into widespread improvements in patient-centered outcomes. This study aimed to compare effectiveness and differential impact of 3 integrated care management delivery methods. STUDY DESIGN: Individual, stratified randomized trial with a 2:2:1 ratio for high-touch (in person), high-tech (remote monitoring), and optimal discharge planning (ODP; telephonic) delivery methods with 12-month follow-up. METHODS: The UPMC Health Plan provided care management to adult Medicaid and Medicare-Medicaid beneficiaries with MCC who were recently discharged from an inpatient hospitalization. Primary (90-day readmission, health status, patient activation) and secondary (30-day readmission; functional status; quality of life; care satisfaction; emergent care use; engagement in primary, specialty, and mental health care; gaps in care) outcomes were assessed. RESULTS: The analytic sample (n = 1387) included Medicaid (79.5%) or dually eligible (20.5%) beneficiaries with MCC (63.0% female, 73.0% White, and 21.6% Black). We found no evidence of a treatment effect on 90-day readmission rates (P = .669). There was a significant improvement over time for health status (P < .0001) but no significant difference by intervention (P = .866). Patient activation showed a significant time-by-treatment interaction (P = .021), with a significant difference (from baseline to 12 months) for the high-touch approach compared with ODP (adjusted difference of 2.69 points; SE = 1.22; P = .028). Participant subgroups (race, age, illness complexity, and comorbid behavioral health conditions) showed no statistically significant differences by interventions or over time on the primary outcomes. CONCLUSIONS: Results demonstrate how health care systems can leverage a variety of impactful, person-centered care management approaches without compromising patient outcomes.
AD - UPMC Center for High-Value Health Care, US Steel Tower, 600 Grant St, 25th Floor, Pittsburgh, PA 15219. Email: williamsk17@upmc.edu.; UPMC Center for High-Value Health Care, Pittsburgh, PA.; Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA.; University at Buffalo, Buffalo, NY.; UPMC Health Plan, Pittsburgh, PA.; Department of Psychiatry, University of Arizona College of Medicine, Tucson, AZ.; Now with Partners in Care Foundation, San Fernando, CA.
AN - 41838981
BT - Am J Manag Care
C5 - Education & Workforce
CP - 4
DA - 04/2026
DO - 10.37765/ajmc.2026.89844
DP - NLM
ET - 20251203
IS - 4
JF - Am J Manag Care
LA - eng
N2 - OBJECTIVES: Health care systems employ community-based solutions to help individuals manage multiple chronic conditions (MCC). Little knowledge exists on how to optimally translate evidence-based integrated care management models into widespread improvements in patient-centered outcomes. This study aimed to compare effectiveness and differential impact of 3 integrated care management delivery methods. STUDY DESIGN: Individual, stratified randomized trial with a 2:2:1 ratio for high-touch (in person), high-tech (remote monitoring), and optimal discharge planning (ODP; telephonic) delivery methods with 12-month follow-up. METHODS: The UPMC Health Plan provided care management to adult Medicaid and Medicare-Medicaid beneficiaries with MCC who were recently discharged from an inpatient hospitalization. Primary (90-day readmission, health status, patient activation) and secondary (30-day readmission; functional status; quality of life; care satisfaction; emergent care use; engagement in primary, specialty, and mental health care; gaps in care) outcomes were assessed. RESULTS: The analytic sample (n = 1387) included Medicaid (79.5%) or dually eligible (20.5%) beneficiaries with MCC (63.0% female, 73.0% White, and 21.6% Black). We found no evidence of a treatment effect on 90-day readmission rates (P = .669). There was a significant improvement over time for health status (P < .0001) but no significant difference by intervention (P = .866). Patient activation showed a significant time-by-treatment interaction (P = .021), with a significant difference (from baseline to 12 months) for the high-touch approach compared with ODP (adjusted difference of 2.69 points; SE = 1.22; P = .028). Participant subgroups (race, age, illness complexity, and comorbid behavioral health conditions) showed no statistically significant differences by interventions or over time on the primary outcomes. CONCLUSIONS: Results demonstrate how health care systems can leverage a variety of impactful, person-centered care management approaches without compromising patient outcomes.
PY - 2026
SN - 1088-0224
SP - 202
EP - 210+
ST - Integrated care for chronic conditions: a randomized care management trial
T1 - Integrated care for chronic conditions: a randomized care management trial
T2 - Am J Manag Care
TI - Integrated care for chronic conditions: a randomized care management trial
U1 - Education & Workforce
U3 - 10.37765/ajmc.2026.89844
VL - 32
VO - 1088-0224
Y1 - 2026
ER -