Care Management of Patients with Complex Health Care Needs

Key Questions Answered
  • What does the evidence show about care management programs for persons with complex needs? What works, and what doesn’t work?
  • How can payment systems and policies be reformed to encourage good care management?
Key Themes and Takeaways

There is strong evidence that care management programs can improve quality of care, but it may take time to see results.

  • Studies that tracked patients for longer periods of time were more likely to show improvements in outcomes, but the effect on cost reduction is less consistent.
  • Hospital-to-home care management programs have had the most success in reducing costs, with lower costs resulting from reduced readmissions. Successful hospital-to-home care management programs include follow-up with patients after discharge.
  • So far, home-based care management programs have failed to demonstrate improved quality or lower costs.
  • Keys to successful care management include specially trained nurse care managers, in-person encounters, physician involvement, and coaching for patients and caregivers.
  • Successful programs tend to be concentrated in organizations that do not use fee-for-service payments, such as Kaiser Permanente, Group Health Cooperative, and the Veterans Health Administration.
Sarah Goodell
Thomas Bodenheimer
Rachel Berry-Millet
Population Addressed
People with Multiple Chronic Conditions
Level of Evidence
Non-systematic Review (with Evidence Grading)
Uploaded to The Playbook