Care Management Plus: Strengthening Primary Care for Patients with Multiple Chronic Conditions

Case Study
Key Questions Answered
  • How can a program improve care and health outcomes for patients with multiple chronic conditions while also benefitting the primary care practices that serve them — and accomplish this in a cost-effective manner?
  • Can care management reduce health care utilization and costs among patients who must manage a complex constellation of medical, behavioral health, and social service needs?
Key Themes and Takeaways

This resource is a case study of Care Management Plus (CM+), a health care delivery model designed to improve the quality and coordination of care for older adults and other patients with multiple chronic conditions. The model is designed to reduce health care costs for these patients and support the primary care providers who care for them. This case study describes the program’s implementation at Intermountain Healthcare, where the CM+ model was developed in the early 2000s, and at Oregon Health & Science University (OHSU), from where it is now disseminated. To date, CM+ has been implemented in 420 primary care clinics nationwide, covering 3 million patients.

  • Patients of all ages have been served by the program at Intermountain, which has made care management a standard feature of its patient-centered medical home model. At OHSU, CM+ has been implemented in five large primary care clinics and serves two populations: (1) middle-age adults with multiple chronic diseases that are often coupled with behavioral health or substance abuse issues and (2) older adults who are growing frail or have multiple chronic conditions and who are at risk of functional decline.
  • Patients may be identified for CM+ using risk stratification, disease condition, and algorithms, but at both Intermountain and OHSU, referral is intentionally flexible and inclusive, with discretion given to the patient’s primary care team.
  • The hallmark of CM+ is a specially trained care manager embedded in the primary care practice and supported by specialized information technology tools. Care managers establish a trusting relationship with patients and help them identify health care goals and ways to overcome any barriers to achieving those goals. Care managers act as educators and coaches, building patients’ self-management skills and self-efficacy. They also provide connections to community resources and support.
Authors
Susan L. Hayes
Douglas McCarthy
Population Addressed
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Level of Evidence
Case Study; Promising Evidence
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