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

Brief
Key Questions Answered
  • What are the best practices for a complex care management (CCM) program?
  • What are the advantages and disadvantages of different approaches?
Key Themes and Takeaways

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.
Authors
Clemens S. Hong
Allison L. Siegel
Timothy G. Ferris
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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