Adding a Measure of Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs
Less “activated” patients are more likely to benefit from care coordination.
Peer-Reviewed Article
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Using Data to Better Serve the Most Complex Patients: Highlights from NGA’s Intensive Work with Seven States
The National Governors Association worked for two years to improve care and lower costs for Medicaid “super-utilizers.”
Brief/Report
Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans
Successful long-term services and supports programs have a single point of accountability, such as a care manager.
Brief/Report
Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program?
A comparison of 18 complex care management programs reveals best practices.
Brief/Report
Effective Management of High-Risk Medicare Populations
A three-pronged strategy can help manage care for Medicare beneficiaries.
Brief/Report
Six Features of Medicare Coordinated Care Demonstration Programs that Cut Hospital Admissions
A study showed that some programs reduced hospitalizations by 8 to 33 percent.
Peer-Reviewed Article
Emergency Department Super-Utilizer Programs: Rural Health Systems Analysis and Technical Assistance Project
This guide describes how to design, implement, and assess a program to reduce preventable ED use.
Implementation Tool
Persistent High Utilization in a Privately Insured Population
This resource takes a close look at individuals with complex needs who are privately insured.
Peer-Reviewed Article
Improving Care for People with Serious Illness Through Innovative Payer-Provider Partnerships
The benefits of, incentives for, and various models to deliver palliative care are described.
Implementation Tool
Person-Centered Care: The Business Case
Federal policy changes have made PCC models of care more financially viable.
Brief/Report
The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations
This study links “authentic healing relationships” with patient motivation and active health management.
Peer-Reviewed Article
Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences
One in five high-need adults reported having an unmet medical need.
Brief/Report
Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers”
Interdisciplinary teams provide support for Medicaid beneficiaries with mental illnesses, addictions, and other needs.
Case Example
Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients
Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs.
Case Example
Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis
Much of the evidence comes from small studies, so further testing is needed.
Brief/Report
The Return on Investment (ROI) Calculator: The Business Case and Person-Centered Care
A calculator that can help build and present business case for serving adults with complex needs.
Implementation Tool
Person-Centered Care: A Definition and Essential Elements
This resource provides a definition and essential elements of person-centered care.
Peer-Reviewed Article
Pursuing Financial Sustainability of Person-Centered Care Models
Setting up data collection systems is important to showing value.
Implementation Tool
Complex Care Management Toolkit
Lessons learned from eight health care organizations can help you design a successful program.
Implementation Tool
High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?
There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups.
Brief/Report