Table 1.
Description of Included Studies
| First Author, Year, (Country) | Design | Setting | Population (CM Intervention Inclusion Criteria) | N | Main Characteristics of the Intervention | Outcom | Methodological Quality Score, % |
|---|---|---|---|---|---|---|---|
| Adam et al,40 2010 (USA) | Nonrandomized trial | Primary care clinic | >8 clinic visits/year with multiple comorbidities (physical, psychiatric and psychosocial issues) | I: 12 C: 8 |
Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include referral to mental health services, review of medication, and care coordination. The PCP presented the care plan to the patient and amended it if needed. | ↓ Clinic visits ↑ Well-being ↑ Patient satisfaction ↑ Quality of care ↑ No show or cancelled appointments No change in hospital admission and ED use |
100 |
| Bodenmann et al,41 2017 (Switzerland) | Randomized controlled trial | ED | >5 ED visits/year | I: 125 C: 125 |
Interdisciplinary mobile team developed care plan based on patient's evaluation. Care plan could include assistance for financial entitlements, education, housing, health insurance, and domestic violence support, as well as referral to mental health services, substance abuse treatment, or a PCP. Team also provided care coordination, counseling on substance abuse (if needed) and use of medical services. They also facilitated communication between health care team members. | No significant changes in ED visits | 75 |
| Brown et al,42 2005 (USA) | Before-after study | Primary care clinic | >1 hospital admission/year, >1 chronic condition, and life expectancy judged to be greater than 3 years | 17 | Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include referral for diagnostic testing or specialists' services and a review of medication. The team also provided care coordination, psychological support, self-management support, and disease management. | ↓ ED visits ↓ Hospital admissions ↓ Length of stay No change in health care costs |
25 |
| Crane et al,43 2012 (USA) | Nonrandomized trial | ED | >6 ED visits/year; low family income | I: 34 C: 36 |
Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include referral for diagnostic testing or specialists' services and review of medication. The team also provided group and individual medical appointments, telephone access to care manager, and group sessions on life-skills support. | ↓ ED visits ↓ ED and inpatient costs ↑ Employment status |
75 |
| Edgren et al,44 2016 (Sweden) | Randomized controlled trial | ED | >3 ED visits/6 months, deemed at risk of high health care use and considered to be receptive to intervention | I: 8,214 C: 3,967 |
Nurse case manager developed, with patient, a care plan based on patient's evaluation. Care plan could include self-management support, patient education, and referrals to other health and social services. Via regular contact by telephone, case manager provided self-management support to patient. They also facilitated communication and supported interactions with health care providers and social services. | ↓ Outpatient care ↓ Inpatient care ↓ ED visits ↓ Health care costs |
25 |
| Grimmer-Somers et al,45 2010 (Australia) | Mixed methods study | Primary care centers | Vulnerable frequent users | Quant: 37 Qual: Unknown |
Interdisciplinary care team developed, with patient, care plan based on patient's evaluation. Care plan could include referrals to other health and social services, self-management support, patient education, goal setting, and involvement in peer-led community group. The team also provided support for language, literacy, social support, and transport barriers. | ↓ ED use ↓ Hospital admissions ↓ Length of stay ↓ Inpatient cost ↓ Outpatient attendance ↓ Patient reflection on their health and other needs ↑ Patient goal-setting |
50 |
| Grinberg et al,46 2016(USA) | Qualitative study | Transitional primary care-postdischarge | >2 hospital admissions/6 months with at least 3 of the following criteria:>2 chronic conditions; >5 outpatient medications; lack of access to health care services; lack of social support; mental health comorbidity; substance abuse or use; homeless | 30 | Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include access to primary care, review of medication, medical appointment accompaniment, assistance for transport, and financial entitlements. The team also provided care coordination and health navigation after hospital discharge. | ↑ Patient motivation ↑ Self-management ↑ Healing relationships |
100 |
| Grover et al,47 2010 (USA) | Before-after study | ED | >5 ED visits/month or concern about ED use raised by staff or identified by California prescription-monitoring program | 85 | Interdisciplinary care team developed care plan based on patient's evaluation. Care plan could include referrals to outpatient and social services as well as restriction of narcotics prescriptions. Patients received letters to inform them of the care plan but had no contact with the team. The care plan was entered in the patient's medical records in the ED for easy access to information by the ED staff. | ↓ ED use ↓ Radiation exposure from diagnostic imaging ↑ Efficacy of referral No change in hospital admissions or most common chief complaint |
75 |
| Hudon et al,48 2015 (Canada) | Qualitative study | Primary care clinics | >3 ED visits and/or hospital admissions/year, >1 chronic condition, and identified by family physician as a frequent user likely to benefit from intervention | 25 patients 8 family members |
Nurse case manager developed, with patient and other health care providers, a care plan based on patient's evaluation. Care plan could include referrals to health and social services and interdisciplinary team meetings (including the patient). The case manager also provided self-management support and care coordination. | ↑ Access to care ↑ Communication ↑ Care coordination ↑ Patient involvement in decision-making ↑ Care transition |
50 |
| McCarty et al,49 2015 (USA) | Before-after study | ED | ≥25 ED visits/year or identified by ED staff as frequent user likely to benefit from intervention | 23 | Interdisciplinary care team developed, with patient, a care plan based on patient’s evaluation. Care plan could include referrals to health care and social services, goal setting, crisis intervention, restriction of narcotic prescriptions, assistance for transport, financial entitlements, and housing. The team also provided care coordination and supported interactions with community services. | ↓ ED visits | 50 |
| Peddie et al,50 2011 (New Zealand) | Nonrandomized trial | ED | ≥10 ED visits/year | I: 87 C: 77 |
Interdisciplinary care team developed care plan based on patient’s evaluation. The care plan could include referrals to a PCP and interdisciplinary team meeting (including the patient). | No change in ED visits | 25 |
| Pope et al,51 2000 (Canada) | Before-after study | ED | Frequent users who had the potential for high ED use, with at least 2 of the following criteria: chronic condition, complex medical condition, substance abuse user, violent behavior or abusive behavior | 24 | Interdisciplinary care team developed care plan based on patient’s evaluation. Care plan could include referrals to health care and social services, restriction of narcotic prescriptions, restriction of ED use, limited interaction with ED staff, and escort by a security guard in the ED. The team also provided counseling and supported interactions with community services. | ↓ ED visits | 25 |
| Reinius et al,52 2013 (Sweden) | Randomized controlled trial | ED | ≥3 ED visits/6 months with the ability to participate in the study based on medical history, number of medications prescribed, and social factors | I: 211 C: 57 |
Same intervention as Edgren et al (2016)44 | ↓ Outpatient care ↓ ED visits ↓ Length of stay ↓ Health care costs ↑ Health status ↑ Patient satisfaction No change in inpatient care, hospital admissions, or mortality |
50 |
| Roberts et al,53 2015 (USA) | Before-after study | Transitional primary care – post discharge | ≥2 hospital admissions/6 months or ≥3 hospital admissions/year with ≥1 chronic condition | 198 | Interdisciplinary care team developed, with patient, care plan based on patient’s evaluation. Care plan could include goal setting, review of medication, assistance for transport, financial entitlements, and housing. The team also provided self-management support, patient education, health navigation, and care coordination. | ↓ ED visits ↓ Hospital admission ↓ Health care costs |
75 |
| Shah et al,54 2011 (USA) | Nonrandomized trial | Primary care center | ≥4 ED visits or hospital admissions or ≥3 hospital admissions or ≥2 hospital admissions and 1 ED visit/ year, with low family income, uninsured, and not eligible for public health insurance program | I: 98 C: 160 |
Case manager developed, with patient, care plan based on patient’s evaluation. Care plan could include referrals to health and social services, goal setting, assistance for transport, financial entitlements, and housing. The case manager also provided care navigation, facilitated communication with health care providers, supported interactions with community services, and provided care transition. | ↓ ED visits ↓ Health care cost No change in hospital admissions or length of stay |
50 |
| Skinner et al,55 2009 (UK) | Before-after study | ED | ≥10 ED visits/6 months or identified by senior health care providers as putting a high demand on unscheduled care services (or at future risk) and who could benefit from intervention | 57 | Interdisciplinary care team developed care plan based on patient’s evaluation. The care plan could include referrals to health care services. | ↓ ED visits | 75 |
| Sledge et al,56 2006 (USA) | Randomized controlled trial | Primary care center | ≥2 hospital admissions/year | I: 47 C: 49 |
Same intervention as Brown et al (2005)42 | ↑ Clinic visits No change in health care use or costs, functional status, patient satisfaction, or medication taking adherence. |
50 |
| Spillane et al,57 1997 (USA) | Randomized controlled trial | ED | ≥10 ED visits/year | I: 27 C: 25 |
Interdisciplinary care team developed care plan based on patient’s evaluation. Care plan could include care recommendation and treatment guidelines for ED staff such as limitation of diagnostic tests and restriction of narcotics prescriptions. The team also provided psychosocial services, care coordination, and liaison with a PCP. | No change in ED visits | 75 |
| Stokes-Buzzelli et al,58 2010 (USA) | Before-after study | ED | Top 100 frequent ED users, or identified as frequent users deemed appropriate for intervention | 36 | Interdisciplinary care team developed care plan based on patient’s evaluation. The care plan could include care suggestions and treatment guidelines (eg, restriction of narcotics prescriptions) for ED staff. | ↓ ED visits ↓ ED contact time ↓ Laboratory tests ordered ↓ ED costs |
75 |
| Weerahandi et al,59 2015 (USA) | Nonrandomized trial | Transitional primary care – postdischarge | ≥1 hospital admission/1 month or 2 hospital admissions/6 months | I: 579 C: 579 |
Social worker case manager, with patient and other health care providers, developed care plan based on patient’s evaluation. Care plan could include referrals to health care and social services, counseling for mental health problems, self-management support, patient activation, assistance with insurance, and medical appointment accompaniment. The case manager also provided care coordination and care transition and facilitated communication between health care providers. | No change in hospital admissions | 50 |
C = control group; CM = case management; ED = emergency department; I = intervention group; PCP = primary care provider; Qual = qualitative study; Quant = quantitative study; UK = United Kingdom; USA = United States of America.