Community Record of Care for Accountable Communities of Health

December 11, 2015

Best practices for managing care High-Risk, High-Cost patients


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Written by Duncan West


The mantra of healthcare in the 21st Century seems to be, “We must better manage the care of high-risk and high-cost patients.” Insights about best practices are emerging from experience outside health maintenance organizations. The American Journal of Managed Care recently had two articles on the topic. The common thread was that data AND human contact are required for success, whether the work is ‘short-listing’ candidates for care management, or coordinating the delivery of care for those short listed. The two articles are discussed in this and a companion post.

The article Attributes common to programs that successfully treat high-need, high-cost patients contains few surprise findings. Key among the findings listed below are at least monthly contact with a care manager who is best embedded in the care team. In the current payment environments the programs bring little new income for providers. Beyond the benefits to patients, the premiere benefit to providers of care management programs is that they allow providers to focus on time with patients on medical conditions, allowing them to leave the office at more reasonable times.

Successful programs have several common characteristics. They:

  • enroll those who will benefit
  • tailor each program to patient need
  • have committed leadership at all levels of the organization
  • embed care coordinators in provider offices where they make direct patient contact
  • have a minimum of one patient contact per month for high cost, high need patients
  • work with data, both from claims and medical records, with data templates customized for patient conditions
  • continually adapt and update their program

MIN-NS is about arming care managers with information about the care their patients receive with daily reports of patient contacts with the care team. MIN-NS can let Emergency Department staff know of a patient’s care manager, and let the care manager know of the ED visit so they can follow up in a timely manner.

Data helps with care, but only in the context of qualified and compassionate care givers who act upon it.