Care Management of Patients with Complex Health Care Needs

Patients with complex health care needs account for a disproportionately high percentage of our nation's annual medical expenditures.

They represent an opportunity to control the growth of health care costs by better managing their conditions, reducing hospitalizations and avoiding emergency department visits.

What is care management?

Care management is a set of activities intended to improve patient care and reduce the need for medical services by enhancing coordination of care, eliminate duplication, and helping patients and caregivers more effectively manage health conditions. These efforts have demonstrated potential to improve quality and control costs for patients with complex conditions.

This synthesis presents findings from a RWJF analysis of care management programs and related research. Download the full brief (PDF) for a more complete synthesis on this issue and listing of source materials.

Key Findings Summary

  • Care management improves quality, but it may take time to see results.

  • Care management programs tergeting the hospital-to-home transition were the most successful in reducing costs.

  • Successful care management programs include specially trained nurse care managers, in-person encouners and physician involvement.

  • Payment reform may improve the success of care management programs and provide incentives to implement them.

Care management is relatively costly. Offering care management to patients who are not expected to be high utilizers of hospital, specialty and emergency department care would not reduce costs. Similarly, care management for patients too sick to benefit is ineffective.

Does care management improve quality and reduce costs?

Patients who are experiencing poor quality outcomes often require more hospitalizations and emergency department visits. For this reason, utilization of high-cost services can be viewed as one marker of inadequate quality of care.

There is strong research evidence that care management improves quality, but the effect on cost reduction is less consistent. Hospital-to-home care management programs have had the most success in reducing costs. Care management in primary care improves quality, but research indicates it may take time to see results. 

Commercial disease management vendors have provided data demonstrating success, but methodological issues call into question these findings. The evidence demonstrating quality improvement is stronger than the evidence on cost reduction.

Care management within integrated multispecialty groups improves quality, but does not consistently reduce costs. The most effective care management programs are those targeting patients discharged from hospitals. Studies have found that care management programs targeting the hospital-to-home transition have reduced hospital readmissions and lowered costs. 

What are the keys to successful care management?

  • In-person encounters: Person-to-person encounters, including home visits, are necessary features of effective care management. Care management relying solely on telephone encounters has not shown success.
  • Training and personnel: Programs with specially trained care managers who have a relatively low workload are most successful. Most care managers are registered nurses (RNs) who work as part of a multidisciplinary team.
  • Physician involvement: Placing care managers with physicians in primary care practices may help facilitate physician involvement.
  • Informal caregivers: Patients with complex health care needs, particularly those with physical or cognitive functional decline, often need the assistance of informal caregivers to actively participate in care management.
  • Coaching: Coaching involves teaching patients and their caregivers how to recognize early warning signs of worsening disease.