Models of Care for High­-Need, High-­Cost Patients: An Evidence Synthesis

Douglas McCarthy
Jamie Ryan
Sarah Klein
October 2015

There are many theories and anecdotes about care models for high-need, high-cost patients, but little information on what really works to improve care for this population. This resource offers a thorough synthesis of the evidence in the literature.

  • Successful models effectively target people who are likely to benefit from the intervention; comprehensively assess individuals’ risks and needs; rely on evidence-based care planning; encourage and empower patients and families to engage in self­ management; coordinate care and communication among patients, families, and providers; and facilitate care transitions and referrals to community resources.
  • Much of the model-specific evidence comes from small studies, so further testing is needed.
  • There are common barriers to the sustainability and spread of these models, such as incongruous financial incentives, workforce culture, and inadequate infrastructure.
  • The resource notes that, based on the evidence, tailoring programs to specific subpopulations and the specific context are important to success.
Posted to The Playbook on
Population Addressed
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • What does the research show about the effectiveness of care models for individuals with complex needs?
  • What do effective models have in common?
  • What gets in the way of their uptake or success?
Level of Evidence
What does this mean?