Shooting for the “triple aim,” a complex care management (CCM) program successfully takes on patients with the highest risk and highest cost.

  • Early data show a 40% reduction in inpatient admissions and 50% drop in ED visits.
  • The CCM saved $6.2 million on Medicare as part of the Medicare Shared Savings Program.
  • Care management teams work with patients’ physicians to determine the best way to engage with patients.

A case management program that seeks to reduce costs, increase quality of care, and provide a better patient experience — the “triple aim” — has shown success in reducing hospital admissions and ED visits.

Called complex care management (CCM), the 16-staff-member program began a few years ago in response to a Massachusetts health system’s decision to become a patient-centered medical home (PCMH).

“As part of that focus, we have an emphasis on taking care of your highest-risk, highest-cost patients in a way that the delivery system is accountable for their care needs,” says Eleni Carr, MBA, LICSW, senior director of care integration at Cambridge Health Alliance in Cambridge, MA.

“These are patients who have multiple comorbidities and chronic disease diagnoses,” she explains. “They drive higher utilization of healthcare services and, often, acute care services.”

The CCM program’s goal was to help these high-risk patients prevent the types of health episodes that were landing them in the ED. Registered nurses and licensed social workers staff the CCM teams. Sometimes the teams include community health workers.

Data suggest the program appears to be working. “Early indications on a small sample group suggested that we reduced inpatient admissions by 40% and emergency department visits by 50%, and we increased primary care provider visits by 106%, so we did what we set out to do,” Carr says.

“These early results were favorable, and that’s why we invested in this model,” Carr adds.

For example, this same population of 77 patients, followed from pre-enrollment to post-enrollment, had an estimated cost avoidance of about $800,000 over two years. Not all of that savings could be attributed to CCM, but it was one component, she says.

The health system also was part of the Medicare Shared Savings Program, saving $6.2 million on Medicare partly due to the complex care management program, Carr says.

Cambridge Health Alliance’s CCM focuses on the top 5% of patients who have high healthcare costs because this small portion of patients are responsible for about 50% of total healthcare costs, Carr explains.

“In addition to chronic medical conditions, these patients frequently carry behavioral health diagnoses — depression, anxiety, and a range of other disorders,” Carr says. “So the health system as it’s designed today has a hard time meeting their healthcare needs effectively.”

The following is how the program works:

Data collection. A data analyst pulls information from various sources, including claims data from payers that has utilization, diagnostic, and medical expense numbers. Data from all patients over the past six months are reviewed. Predictive analytic software helps the analyst predict which patients might use excessive healthcare services in the coming year. The tool can predict risk of hospitalization and other cost-drivers, such as ED visits, Carr explains.

“Every three to four months, we compile a list of approximately 1,000 patients of our total panel,” Carr says. “Then we make some decisions about which of these are the highest-risk patients, and those are the ones we focus on.”

For example, a patient might have a new diagnosis, such as heart failure or cancer, which could drive potential future costs. Prescription costs also are analyzed.

“Our pipeline has been refined now over the past year or two to extract the most poignant information by which we can make decisions,” Carr says.

Give CCM teams lists of patients. “We ask teams to review these patients and consult with their primary care providers [PCPs] and evaluate whether they think care management services would be helpful in improving their health and managing costs,” Carr says.

The typical CCM team consists of one nurse and one social worker, who each have a caseload of about 60 patients. They consult with each other on the more complicated patient cases.

“The idea is for the teams to engage with the patient over a six-to-eight-month period,” Carr says. “They seek to understand where the patient is and what their health goals are, what their strengths and barriers to care might be.”

They also develop strategies and action steps to help patients while maintaining frequent communication with primary care providers. “If a patient heads to the emergency room, we want it to be for an emergency, not just because they aren’t getting a visit with their doctor,” Carr says. “Whenever possible, we want to take care of their needs outside of acute settings.”

Develop strategy for engagement. The care management team works with the patient’s physician to determine the best approach to engage the patient. Ideally, this occurs face-to-face where the physician might say, “I’d like to introduce you to our care managers, who can help you with your diabetes,” Carr says.

Care managers can offer periodic check-ins, care coordination among specialists, health coaching, and more, she suggests.

Patients sign up for the care management voluntarily, but once they do they can receive help with more than their healthcare, including finding healthy food in their neighborhoods, transportation, and help with practical and social support. (For more information, see case studies in this issue.)

“Once a patient signs up, we have a drill, beginning with an assessment that drives a care plan, and we start working with patients where they are,” Carr says. “We recognize they’re struggling, so we find out how we can help them, and it’s sometimes with very practical things.”

Resolve care management. Often, patients achieve their goals, and care management has a happy ending in which the patient feels better, is more stable, and can manage without care management support, Carr says.

Some patients end their own care management before the CCM team can say they have reached their goals, and other times patients who fail to work on goals are discharged until they are willing to work at improving their health, she adds.

“We say, ‘It seems you’re not able to do the work to get healthier right now, so when you feel more ready, call and we’ll come back again,’” she says.

The program will have more outcomes data available this spring, but for now it appears to be doing what it was designed to do, Carr says.

“I think complex care management is an effective intervention to help meet the needs of patients in your highest risk cohort,” she says. “In time, I think we will find that it will improve care, improve patient experience, and improve healthcare value.”