Evaluation of CMS Transitional Care and Chronic Care Management Services: Bridging the Gap and Maximizing Potential

PROJECT SUMMARY With increasing life expectancy of US population, healthcare systems are faced with the challenge of improving the health of older adults while containing healthcare costs. The health outcomes and healthcare costs of older adults are significantly influenced by multimorbidity, frailty, and poor social determinants of health. There is an

increasing effort to shift disease-based care toward patient-centered care that addresses patients' medical and psychosocial needs and enhances care coordination. To this end, the Centers for Medicare & Medicaid Services introduced Transitional Care Management (TCM) in 2013 and Chronic Care Management (CCM) services in

2015. Despite the premise of these services, they are not delivered to patients who need these services most. The objective of this proposed research is to narrow this practice gap by evaluating the effectiveness of TCM and CCM and develop strategies to increase adoption of these services. The central hypothesis of this project

is that TCM and CCM services are more effective in increasing days at home (home time), survival, and reducing total Medicare costs than usual care in older adults, particularly those with frailty, dementia, and poor social determinants of health; the uptake of these services is affected by patient-level, caregiver-level, and practice-

level factors. A team of experts in geriatrics, health services research, causal inference, health economics, and qualitative research will accomplish the following specific aims: 1) determine the effectiveness of TCM and CCM on home time, survival, and healthcare costs by emulating target trials of TCM and CCM in Medicare fee-for-

service and Medicare Advantage beneficiaries; 2) develop and validate prediction models to identify patients who are more likely to benefit from TCM and CCM; and 3) identify patient-level, caregiver-level, and practice- level facilitators and barriers in adopting TCM and CCM by conducting a large, multiregional qualitative study of

30 practices of high-volume, low-volume, and former use of TCM and CCM. The innovation of this research includes its target trial emulation approach to evaluate the effectiveness of TCM and CCM compared with usual care; use of patient-centered outcome home time; inclusion of contemporary Medicare fee-for-service and

Medicare Advantage beneficiaries; and mixed methods approach of conducting a multi-regional qualitative study informed by a quantitative analysis of the national Medicare data. This research is significant because the results can inform development of strategies to increase clinical adoption of TCM and CCM services in beneficiaries

who are most likely to benefit from each service. Ultimately, appropriate use of TCM and CCM will enhance patient-centered coordinated care and reduce healthcare costs in aging populations.