There are many theories and anecdotes about care models for high-need, high-cost patients, but little information on what really works to improve care for this population. This resource offers a thorough synthesis of the evidence in the literature.
- Successful models effectively target people who are likely to benefit from the intervention; comprehensively assess individuals’ risks and needs; rely on evidence-based care planning; encourage and empower patients and families to engage in self management; coordinate care and communication among patients, families, and providers; and facilitate care transitions and referrals to community resources.
- Much of the model-specific evidence comes from small studies, so further testing is needed.
- There are common barriers to the sustainability and spread of these models, such as incongruous financial incentives, workforce culture, and inadequate infrastructure.
- The resource notes that, based on the evidence, tailoring programs to specific subpopulations and the specific context are important to success.
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Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
- What does the research show about the effectiveness of care models for individuals with complex needs?
- What do effective models have in common?
- What gets in the way of their uptake or success?
Level of Evidence
ModerateWhat does this mean?