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

Clemens S. Hong
Allison L. Siegel
Timothy G. Ferris
August 2014

This resource compares the operational approaches of 18 successful CCM programs for high-need, high-cost patients to offer guidance on best practices.

  • CCM programs must be tailored to their particular context; for example, small, independent practices may need to share CCM resources with each other.
  • To select individuals for the program, the most reliable approach combines use of risk prediction software, chronic disease criteria, and referrals or assessments.
  • Effective programs frequently build multidisciplinary CCM teams around one or more primary care manager(s), and it’s essential to build warm, trusting relationships among individuals and their primary care providers.
  • Because complex care coordination is a specialized skill, customized training for team members is critical.
  • Technology can be helpful as a means to access real-time data (e.g., on hospital discharges), facilitate communication, provide automated reminders, and enable remote patient monitoring.
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Population Addressed
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • What are the best practices for a complex care management (CCM) program?
  • What are the advantages and disadvantages of different approaches?
Level of Evidence
What does this mean?