Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Michael Hochman
Steven Asch
Case Example
April 2017

This resource offers a clinical vignette highlighting the challenges of caring for persons with complex needs, followed by descriptions of two approaches for managing these populations, and finally policy suggestions.

  • One approach is complex case management, also called complex care management. These services include connecting patients with social service programs, identifying psychological or behavioral health needs, and providing disease management. The services may be provided by an array of providers, including social workers, nurses, medical assistants, and community health workers.
  • Another approach involves specialized clinics offering complex case management resources concentrated in one place. So far, research suggests that this approach may be more effective.
  • To promote these approaches, a shift is needed towards risk-bearing arrangements, value-based reimbursement models, and shared-savings programs like accountable care organizations.
  • There is also a need for better integration of medical, behavioral health, and social service delivery.
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