• managed care;
  • care management;
  • home- and community-based services

OBJECTIVES: To determine whether a telephone care-management intervention for high-risk Medicare health maintenance organization (HMO) health plan enrollees can reduce costly medical service utilization.

DESIGN: Randomized, controlled trial measuring healthcare services utilization over three 12-month periods (pre-, during, and postintervention).

SETTING: Two social service organizations partnered with a Medicare HMO and four contracted medical groups in southern California.

PARTICIPANTS: Eight hundred twenty-three patients aged 65 and older; eligibility was determined using an algorithm to target older adults with high use of insured healthcare services.

INTERVENTION: After assessment, members in the intervention group were offered mutually agreed upon referrals to home- and community-based services (HCBS), medical groups, or Medicare HMO health plan and followed monthly for 1 year.

MEASUREMENTS: Insured medical service utilization was measured across three 12-month periods. Acceptance and utilization of Care Advocate (CA) referrals were measured during the 12-month intervention period.

RESULTS: CA intervention members were significantly more likely than controls to use primary care physician services (odds ratio (OR)=2.05, P<.001), and number of hospital admissions (OR=0.43, P<.01) and hospital days (OR=0.39, P<.05) were significantly more stable for CA group members than for controls.

CONCLUSION: Results suggest that a modest intervention linking older adults to HCBS may have important cost-saving implications for HMOs serving community-dwelling older adults with high healthcare service utilization. Future studies, using a national sample, should verify the role of telephone care management in reducing the use of costly medical services.