Innovative Complex Care Management Programs: Common Themes from the Super-Utilizer Summit

Diane Hasselman
October 2013

In 2013, the Center for Health Care Strategies, Inc., hosted a “Super-Utilizer Summit” to explore how Medicaid could promote models to improve care and lower costs for individuals whose complex needs are not well met by the health care system. The resource covers common themes and key recommendations from the Summit, with brief case studies and appendices with educational resources for states and policymakers.

  • Strategies fall into three areas: data collection and analysis to identify a patient population; care teams and care management; and integration, replication, and sustainability of programs.
  • Most care teams include some combination of nursing, social work, and community outreach expertise.
  • Interventions typically include extensive outreach, a 24-hour on-call system, and medication management.
  • Teams tend to “front-load” social services; that is, case managers or social workers often make the first connection with the person in need of services, to try to meet basic needs such as housing first.
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Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • What are the elements of an effective program for so-called “super-utilizers”?
  • How can organizations use a variety of data to identify and segment the population?
  • What are the elements of an effective care management program?
  • How can you sustain programs for individuals with complex needs?
Level of Evidence
Expert Opinion
What does this mean?