Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients Provider incentives must be based on Triple Aim outcomes. Brief/Report May 2016
Care Management Plus: Strengthening Primary Care for Patients with Multiple Chronic Conditions A program to help clinics deliver comprehensive care may decrease mortality and hospitalization rates. Case Example December 2016
What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs Experts describe how delivery systems can effectively serve adults with complex needs. Brief/Report September 2016
High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups. Brief/Report August 2016
How High-Need Patients Experience the Health Care System in Nine Countries The U.S. had the highest rate of cost-related access problems. Brief/Report January 2016
Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individuals Targeting is important, even within the high-need patients enrolled in the program. Peer-Reviewed Article November 2015
Generating Hypotheses about Care Needs of High Utilizers: Lessons from Patient Interviews This resource presents promising ideas for more effective modes of care for persons with complex needs. Peer-Reviewed Article September 2013
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home. Case Example August 2016
The Care Transitions Intervention The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials. Implementation Tool November 2016
Adding a Measure of Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs Less “activated” patients are more likely to benefit from care coordination. Peer-Reviewed Article March 2016
Using Data to Better Serve the Most Complex Patients: Highlights from NGA’s Intensive Work with Seven States The National Governors Association worked for two years to improve care and lower costs for Medicaid “super-utilizers.” Brief/Report August 2019
Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans Successful long-term services and supports programs have a single point of accountability, such as a care manager. Brief/Report April 2016
Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program? A comparison of 18 complex care management programs reveals best practices. Brief/Report August 2014
Effective Management of High-Risk Medicare Populations A three-pronged strategy can help manage care for Medicare beneficiaries. Brief/Report September 2014
Six Features of Medicare Coordinated Care Demonstration Programs that Cut Hospital Admissions A study showed that some programs reduced hospitalizations by 8 to 33 percent. Peer-Reviewed Article June 2012
Emergency Department Super-Utilizer Programs: Rural Health Systems Analysis and Technical Assistance Project This guide describes how to design, implement, and assess a program to reduce preventable ED use. Implementation Tool October 2013
Persistent High Utilization in a Privately Insured Population This resource takes a close look at individuals with complex needs who are privately insured. Peer-Reviewed Article April 2015
Person-Centered Care: The Business Case Federal policy changes have made PCC models of care more financially viable. Brief/Report June 2016
The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations This study links “authentic healing relationships” with patient motivation and active health management. Peer-Reviewed Article August 2016
Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences One in five high-need adults reported having an unmet medical need. Brief/Report August 2016