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

Hong CS, Siegel AL, Ferris TG
Publication Year: 2014
Patient Need Addressed: Behavioral health, Chronic Conditions
Population Focus: Complex care
Intervention Type: Service redesign, Staff design and care management
Study Design: Other Study Design
Type of Literature: Grey

Provider groups taking on risk for the overall costs of care in accountable care organizations are developing care management programs to improve care and thereby control costs. Many such programs target “high-need, high-cost” patients: those with multiple or complex conditions, often combined with behavioral health problems or socioeconomic challenges. In this study we compared the operational approaches of 18 successful complex care management programs in order to offer guidance to providers, payers, and policymakers on best practices for complex care management. We found that effective programs customize their approach to their local contexts and caseloads; use a combination of qualitative and quantitative methods to identify patients; consider care coordination one of their key roles; focus on building trusting relationships with patients as well as their primary care providers; match team composition and interventions to patient needs; offer specialized training for team members; and use technology to bolster their efforts.

Insights Results

Overview of article

  • This study focused on complex care management (CCM), which are programs in which specially trained, multidisciplinary teams coordinate closely with primary care teams to meet the needs of patients with multiple chronic conditions or advanced illness, many of whom face social or economic barriers in accessing services programs
  • To help guide healthcare providers, administrators, health system leaders, and payers that are investing in and implementing interventions for complex, high-cost patients, this brief describes the models and best practices of 18 successful CCM programs. This brief identified programs through literature review, recommendations of an expert steering committee, and snowball sampling

Methods of article

  • This brief identified programs through literature review, recommendations of an expert steering committee, and snowball sampling
  • The aim of the study was to identify key operational attributes and best practices of successful primary care– integrated complex care management (PC-CCM) programs. Authors posed the following primary research questions: 1) What are the core operational attributes and best practices of successful programs?; and 2) How are successful programs customized for specific populations or contexts?
  • Authors selected sites for potential inclusion in the study based on review of the peer-reviewed and grey literature and snowball sampling, starting with recommendations from an eight-member expert steering committee and involving study participants. Based on inclusion criteria approved by the study steering committee, authors selected 20 total sites for inclusion in the study. The criteria were: 1) Focus on complex populations: PC-CCM programs must select a complex population that they deem to be at increased risk for poor health outcomes or high cost (based on any definition); 2) Aligned with primary care: close integration with existing primary care teams; 3) Comprehensive care management focus: focus on the whole person and multimorbidity, rather than a single disease process; 4) Existing data on performance indicating improved outcomes; and 5) Currently in operation
  • Each site received at least two email invitations to participate in the study. Once sites agreed to participate, they chose a representative site in their system and identified three key informants for interview
  • Authors assessed each program using semi structured key-informant interviews and review of published manuscripts and program materials obtained from each of the sites. Authors performed at least three one-hour, semi structured interviews per site with the following key informants: 1) an executive leader involved in developing or supporting the PCCCM program; 2) A program director responsible for managing program operation; and 3) A frontline care manager responsible for direct delivery of care to patients
  • Authors assessed six study domains through these semi structured interviews: 1) Program context and structure; 2) Patient selection; 3) CCM team construct; 4) Scope of work; 5) Hiring and training; and 6) Use of information technology
  • Twenty sites were selected for final inclusion in the study, and 18 sites completed the semi structured interviews. Authors reviewed program outcomes and ensured that each program met basic criteria for success, defined as positive findings in at least one quality domain and one cost or utilization domain


  • CCM programs must be tailored to their particular context. Contextual factors include practice size, location in an urban or rural area, and program sponsorship and governance. For example, Camden Coalition uses a tailored approach to introduce its program to prospective patients. First, a team member tries to approach prospective patients during a hospitalization or emergency department visit—when they are likely to have a number of acute needs and thus be receptive to offers of help. Then, instead of generically presenting Camden Coalition’s services, a team member asks open-ended questions. Armed with an understanding of a patient’s priorities and needs, the team member can then tailor the presentation of Camden’s services to those needs. The coalition reports that few patients decline services when approached in this way
  • CCM programs aim to identify individuals who are at the highest risk for poor outcomes and who would benefit from the planned care management interventions. This requires alignment between selected populations, interventions, and desired outcomes, and a combined quantitative and qualitative approach appears to work best
  • The composition of the CCM team must be tailored to the target population and constructed to effectively deliver the desired outcomes
  • The needs of the patients being served and the CCM team composition determine the appropriate caseload as well as the frequency and location of interactions
  • The key task for the CCM team is to build trusting relationships with patients/families as well as with primary care providers and their staff
  • To perform their key role of coordinating patients’ care, CCM teams must ensure all providers share information, secure smooth referrals, and help patients find needed resources in health systems and in communities
  • Care coordination is a specialized field like any other: team members require customized training, including both didactic experiences and mentoring/shadowing
  • Health information technology can be a powerful enabler of effective care management, though there are significant gaps in functionality among existing tools. For example, The Geriatric Resources for Assessment and Care of Elders (GRACE) program, developed at the Indianapolis-based Wishard Health Services, was created to manage the care of vulnerable elderly patients by an interdisciplinary geriatrics team
  • To develop care plans, team members consider: dementia, depression, ambulation, urinary continence, nutrition, pain, vision, hearing, medications, health maintenance, advance care planning, and caregiver burden. A nurse practitioner and social worker also assess patients in their homes and then follow standard protocols to develop plans based on their findings. Plans are then presented to the full care management team, whose members prioritize interventions and generate reports for patients’ primary care physicians, who review them and provide feedback. The nurse practitioner and social worker then review each plan with patients to ensure they are consistent with their preferences before implementing them. The assessment and care plan are maintained in a central information technology system, enabling the care manager

Key takeaways/implications

  • While the evolving nature of CCM made identifying best practices difficult, program leaders and team members endorsed several operational approaches. Perhaps most important, they thought that they had not exhausted the opportunities to improve care and reduce cost for these complex patients. Both the emergence of key operational characteristics of successful programs and the apparent opportunity for continued improvement of these programs should spur policymakers to reduce barriers to more widespread adoption of primary care–integrated, complex care management programs
  • This brief highlighted that CareOregon is an example of successfully avoiding unnecessary utilization. CareOregon care managers engage patients in the emergency department (ED) with the goal of connecting high utilizers with patient-centered medical homes. Previously developed ED treatment plans are faxed to the ED at the time of the patient visit. The treatment plan includes reminders to call the CCM program outreach workers and direct the patient back to the primary care practice. This planning style could be more widely adopted