- Which psychosocial factors should I take into account to identify high-risk Medicare beneficiaries?
- Who are individuals with complex needs?
- Why invest in models of care to improve care for individuals with complex needs?
- What care models work to improve care for individuals with complex needs?
This resource, drawing on Medicare survey and claims data, a literature review, and interviews, suggests a three-pronged strategy to manage care for Medicare beneficiaries with medical and social needs.
- The first step is to pinpoint the relevant risk factors, including functional and cognitive impairments.
- The next step is to improve data collection, such as by adding questions to existing health-risk assessments that go beyond the usual medical and financial questions.
- Finally, you should implement targeted programs to manage transitions and coordinate care for high-risk members.
- The study’s analysis of return on investment (ROI) indicates that targeted care coordination programs can yield an ROI of 250 percent.