CHA News Article

Report: Best Practices for Identifying Complex Care Management Patients

The California HealthCare Foundation (CHCF) has released a report that outlines how successful complex care management (CCM) programs identify and engage high-risk patients, assess their needs and intervene rapidly to change their health status. Titled Finding a Match: How Successful Complex Care Programs Identify Patients, the report examines various quantitative, qualitative and hybrid approach methods that CCM programs use to identify patients. It discusses two key aspects of patient identification: 1) predicting risk in patients based on characteristics or outcomes such as inpatient admissions or recurrent, unnecessary emergency department visits; and 2) predicting care sensitivity — the likelihood that a particular high-risk patient will respond to the interventions available within the program.

The report highlights a variety of strategies — including their strengths and weaknesses — that were identified during in-depth interviews with leaders at 20 well established CCM programs. It also includes examples of successful case strategies and a list of useful takeaways for organizations seeking to create or improve a CCM program. The full report is attached.