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

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? 
Key Themes and Takeaways

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.
Randall S. Brown
Deborah Peikes
Greg Peterson
Jennifer Schore
Carol M. Razafindrakoto
Population Addressed
People with Multiple Chronic Conditions
Level of Evidence
Randomized Study; Strong Evidence
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