Cross-Continuum Tool Is Associated with Reduced Utilization and Cost for Frequent High-Need Users

Key Questions Answered
  • What is a promising tool for addressing fragmentation in the health system and helping providers understand the patient’s whole story?
  • How does this tool work, and what is the evidence for its success?
Key Themes and Takeaways

This resource describes the Complex Care Map (CCM ©), a tool that addresses fragmentation in the health system and helps providers understand the patient’s story. It was implemented in a quality improvement project at a Midwestern urban hospital for patients with complex needs.


  • A clinical nurse leader created a Complex Care Resource Center, where tools were developed to identify causes of instability, all of the patient’s providers, and drivers that could improve outcomes for the patient.
  • The CCM© is linked to a pop-up alert that fires the first time a provider opens the medical record. It allows each provider to examine the history and considerations for care from the patient’s continuum of providers. The CCM© captures the patient’s story and surfaces considerations to improve delivery of care.
  • The authors compared utilization, cost, social, and health care access variables for 12 months before and after implementation.
  • On average, ED visits decreased 43 percent, inpatient admissions decreased 44 percent, and outpatient visits decreased 17 percent. Moreover, patients with housing increased 14 percent, those with primary care increased 15 percent, and those with insurance increased 16 percent. Costs also declined.
Lauran Hardin
Adam Kilian
Leslie Muller
Kevin Callison
Michael Olgren
Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Level of Evidence
Promising Evidence
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