Complex Care Management Toolkit

Key Questions Answered
  • How can I implement a care management program for individuals with complex needs?
  • How can I improve an existing program for these individuals?
  • What resources and tools are available to help?
Key Themes and Takeaways

This resource harvests the lessons learned from eight health care organizations that successfully developed programs for individuals with multiple chronic conditions and functional limitations.

  • Ten key questions can help you find out if you’re ready to redesign care for individuals with complex needs.
  • The resource lists key steps in redesigning care: identifying target patients, designing a complex care management model, assigning roles to the care team, engaging physicians and office staff, enrolling and engaging patients, and developing a measurement plan.
  • For each step, the guide recommends changes to try and identifies resources for further reading. 
Giovanna Giuliani
Diane Stewart
Sophia Chang
Jan Eldred
Kate Chenok
Pranav Kothari
Population Addressed
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Level of Evidence
Expert Opinion
Uploaded to The Playbook