Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program?

Authors
Clemens S. Hong
Allison L. Siegel
Timothy G. Ferris
Brief/Report
August 2014

This resource compares the operational approaches of 18 successful CCM programs for high-need, high-cost patients to offer guidance on best practices.

  • CCM programs must be tailored to their particular context; for example, small, independent practices may need to share CCM resources with each other.
  • To select individuals for the program, the most reliable approach combines use of risk prediction software, chronic disease criteria, and referrals or assessments.
  • Effective programs frequently build multidisciplinary CCM teams around one or more primary care manager(s), and it’s essential to build warm, trusting relationships among individuals and their primary care providers.
  • Because complex care coordination is a specialized skill, customized training for team members is critical.
  • Technology can be helpful as a means to access real-time data (e.g., on hospital discharges), facilitate communication, provide automated reminders, and enable remote patient monitoring.
Posted to The Playbook on
Key Questions Answered
  • What are the best practices for a complex care management (CCM) program?
  • What are the advantages and disadvantages of different approaches?
Level of Evidence
Promising
What does this mean?