Helping the Highest-Need Patients Manage Their Health
<p>The Commonwealth Fund’s continuing series <em>Models for High-Need, High-Cost Patients</em> next profiles a program that targets a population requiring a greater level of support than primary care practices are typically equipped to provide: adults who have multiple chronic diseases and often behavioral health and social needs as well.</p><p>The program, known as Care Management Plus, is centered on the care manager, who as an embedded member of the primary care team works with patients to identify goals and develop and implement plans for care, provides coaching in self-management skills, and refers clients to resources and other support in the community. A sophisticated, adaptable web application linked to the electronic health record provides the care team with tracking tools, generates reminders, assesses for depression and functional status, and produces a patient "worksheet."</p>
<p>Now implemented in 420 primary care clinics nationwide, the model has been shown to lower mortality rates and, for patients with diabetes, reduce the need for hospitalization. It has also been shown to increase provider productivity and satisfaction. </p>