Six Features of Medicare Coordinated Care Demonstration Programs that Cut Hospital Admissions

Randall S. Brown
Deborah Peikes
Greg Peterson
Jennifer Schore
Carol M. Razafindrakoto
Journal Article
June 2012

This resource reviews the results of the Medicare Coordinated Care Demonstration, a randomized controlled trial with 15 programs that tested whether paying programs to provide care management reduced costs and improved outcomes.

  • The paper found that over six years, four of the programs reduced hospitalizations by 8 to 33 percent among high-risk enrollees.
  • Among these four effective programs, six approaches were consistently present: 1) frequent face-to-face contact with patients; 2) occasionally meeting in person with providers; 3) acting as a “communications hub,” i.e., making sure that all providers had key information about patients; 4) offering patients evidence-based education, including about recognizing symptoms and diet and exercise regimens; 5) strong medication management; and 6) transitional care after hospitalizations.
  • Overall, the findings indicated that care coordination can reduce the need for hospitalizations if targeted to appropriate people.
  • However, the approaches would save money only if intervention costs are kept to about $125 to $150 per member per month.
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Population Addressed
People with Multiple Chronic Conditions
Key Questions Answered
  • Which features of care coordination programs lead to lower rates of hospital readmission for people with multiple chronic conditions?
  • How much can my organization spend on a program without spending more than we are saving? 
Level of Evidence
What does this mean?