Developing Care Management Programs to Serve High-Need, High-Cost Populations

February 2016

As the health care system shifts from a fee-for-service structure to value-based payment programs, it’s important to offer appropriate services across the continuum of care. This resource reviews lessons learned and opportunities for improvement. It also includes detailed case studies.

  • Forming meaningful partnerships with patients and family caregivers occurs not just at the point of care, but also at the system design level and at the community level.
  • Care management programs should include processes for evaluating patient-reported outcomes (PROs). PROs provide information such as health status and behavior, severity of pain, physical functioning, quality of life, etc.
  • Programs should collect information on low- and no-value care in order to reduce waste, improve care, and lower costs.
  • There is no one-size-fits-all approach for care management.
  • Successful care management programs respond to the specific needs of the patient. Programs and plans should be continuously assessed and adapted to the ever-changing needs of the patient.
  • Providers who are philosophically aligned with the program, have a track record in improvement, and have a financial stake in the program’s success may provide the strongest leadership.
  • For patients, education and peer support are critical.
Posted to The Playbook on
Population Addressed
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • What are the features of successful care management programs for high-need patients?
  • What are some ways to engage patients and caregivers in the continuum of care?
  • What are some examples of successful programs?
Level of Evidence
Expert Opinion
What does this mean?