This resource compares the operational approaches of 18 successful CCM programs for high-need, high-cost patients to offer guidance on best practices.
- CCM programs must be tailored to their particular context; for example, small, independent practices may need to share CCM resources with each other.
- To select individuals for the program, the most reliable approach combines use of risk prediction software, chronic disease criteria, and referrals or assessments.
- Effective programs frequently build multidisciplinary CCM teams around one or more primary care manager(s), and it’s essential to build warm, trusting relationships among individuals and their primary care providers.
- Because complex care coordination is a specialized skill, customized training for team members is critical.
- Technology can be helpful as a means to access real-time data (e.g., on hospital discharges), facilitate communication, provide automated reminders, and enable remote patient monitoring.
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