Intense Care Management Shows Promise for Patients With Complex Medical Needs

Published Online: Tuesday, November 20th, 2018
“Super-utilizers,” or patients with complex health issues and frequent hospital visits, are becoming a focus of care management programs in an effort to improve patient outcomes. However, evidence on their effectiveness is slim. A study published in The American Journal of Managed Care® (AJMC®) found that Medicare fee-for-service patients in 4 states who fit this category and were enrolled in a high-intensity care management program had 37% fewer unplanned hospital readmissions than a matched comparison group.

Investigators from Mathematica Policy Research conducted an evaluation of a project by the Rutgers University Center for State Health Policy, which received a $14.3 million healthcare innovation award from the Center for Medicare and Medicaid Innovation to replicate a nationally known team-based care model in California, Colorado, Missouri, and Pennsylvania.

The care model was created by the Camden Coalition of Healthcare Providers, a nonprofit that uses interdisciplinary, community-based care management to focus on the social determinants of health (SDOH) in Camden, NJ.

While the healthcare providers in this study varied, they had one thing in common: The intense care management program aimed to improve the health of patients with complex needs, many of whom lived in poverty, including by improving their SDOH by connecting them to community resources.

“The Camden Coalition is very encouraged by these strong results, which come from four very different places across the country where local provider groups stood up complex care models tailored to their own communities,” said Kathleen Noonan, chief executive officer of the Camden Coalition. “We’re pleased to have had a part in the development of their interventions, and in the evolution of the complex care field. These findings show the promise of whole-person approaches to care management, and the importance of focusing on social factors that drive health outcomes.”

“Our work contributes to the body of evidence on how care management programs may improve patient outcomes,” said Dr. Purvi Sevak, senior researcher at Mathematica Policy Research. “Our findings on this adaptation of the Camden super-utilizer program provide insight into the ability to replicate program impacts in different settings. While these results are promising, this model will need further testing at larger scales before it is possible to make stronger conclusions about its impacts.”

The study was limited by its small sample size (149 participants), and the researchers noted that a larger, randomized controlled trial of the Camden model is underway. Regardless, the mobile interdisciplinary care team model shows promise for reducing all-cause admissions, ambulatory care–sensitive condition admissions, and Medicare parts A and B spending, the researchers wrote.

This article was originally published by the American Journal of Managed CareFor more information, visit

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