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Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individuals

hospital patients health care


Care delivery models designed to improve health outcomes and reduce spending for patients with complex health needs vary in their effectiveness. To identify attributes shared by the more successful programs, Commonwealth Fund–supported researchers reviewed more than 1,000 journal articles and reports and interviewed program leaders.

What the Study Found

Programs that achieved at least one of three aims—reduced spending, increased patient satisfaction, or improved clinical outcomes—shared several of the following characteristics:

  • targeted patients who were amenable to change and most likely to benefit from the intervention;
  • had leadership teams whose members reflected a range of clinical and operational disciplines, including physicians, nurses, social workers, pharmacy, and operations;
  • facilitated communication among team members—often through face-to-face contact—and reduced the work burden of physicians;
  • focused on care transitions;
  • periodically updated processes to reflect new information and adjust to patients’ changing needs;
  • found varying ways to interact with patients and their families; and
  • provided data feedback to clinicians and care coordinators.


Accountable care organizations, health plans, and clinicians can build more effective, sustainable programs for high-need, high-cost populations by adopting features shared by the most successful models.

Publication Details



Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]


G. F. Anderson, J. Ballreich, S. Bleich et al., “Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individuals,” American Journal of Managed Care, published online Nov. 10, 2015.