Many different care management program models have been implemented for high-need, high-cost (HNHC) populations, with programs varying widely in their impact on patient outcomes and satisfaction and health care spending. To understand what successful care management programs have in common, this study examined 10 successful care management programs serving HNHC populations around the nation. The targeted programs had varied program sponsors including payers and health systems, and were geographically diverse.
The 10 common attributes across all or most of the programs were:
- Employ social workers or behavioral health specialists as part of interdisciplinary care teams;
- Segment patients based on medical and behavioral health needs when assigning primary care managers;
- Implement care manager as the main point of contact between the patient and care team;
- Standardize protocols for new patient enrollment and care transitions, but promote care manager autonomy in other situations;
- Adapt communication and meeting protocols based on the needs of the clinical sites;
- Regionalize care teams to enable consistent relationships between care managers and other providers and staff;
- Locate most embedded care managers at a single site when the patient population is sufficient;
- Use a common electronic platform to share information, including a shared care plan, with the care team;
- Track cost and utilization metrics and share this information across care team; and
- Coordinate services with internal and external organizations to avoid redundancy.
Understanding these common attributes may help other health care organizations develop effective care management programs.