Care Management Best Practices for High-Need, High-Cost Patients

New White Paper Evaluates Care Management Programs to Identify Building Blocks of Success and Help Health Systems, Payers, and Policymakers Enhance their Strategies

WASHINGTON (February 23, 2016) –The Health Care Transformation Task Force, a consortium of patients, payers, providers and purchasers working to transform the U.S. health care system, today released a white paper that identifies the building blocks of successful care management for high-need, high-cost patients, presents case studies of Task Force member care management programs, and identifies lessons learned and important areas for improvement.

The paper – “Developing Care Management Programs to Serve High-Need, High-Cost Populations”– draws on the evidence and experience of clinically and financially successful programs across the country.

“Our goal is to help health systems, payers, and policymakers enhance person-centered care management strategies, highlight opportunities for alignment, and identify areas where more evidence may be needed to understand the cost and quality impact of care coordination,” said Task Force Executive Director Jeff Micklos. “As appropriate care management services for this population continue to mature, innovative payment models must also be developed to promote effective and accountable delivery of these services.”

Experts from the Task Force’s Improving Care for High-Cost Patients Work Group, composed of Task Force members and partner organizations, identified five lessons learned and opportunities for improvement:

  1. Ensure Meaningful Patient and Caregiver Engagement – Engage patients and informal caregivers, including family, at all levels of care delivery is integral to the success of care management programs. At the community level, patients and caregivers can help bridge a potential gap between acute care and community-based care management resources.
  2. Evaluate Care Management – The Task Force recommends that care management programs include processes for evaluating patient-reported outcomes (PROs) and low- or no-value care.
  3. Define the Scope of Care Management Programs – There is no one-size-fits-all approach for care management. Each program serves its own patient population, reflective of local demographics.
  4. Tailor Care Management Programs to Individual Patients – Successful care management programs respond to the specific needs of the patient. This is made possible through the establishment of a trusting relationship at the outset of care.
  5. Overcome Resistance to Services – Providers who are philosophically aligned with the program, have a track record in improvement, and who are financial invested in the program’s success may provide the strongest leadership for an effective program. For patients, education, patience, empathy, and peer support are critical in overcoming the fear, anxiety, shame, distrust, or other factors that may influence patient resistance to services.

The white paper is the second in a series of three papers to be developed by the Task Force’s Improving Care for High-Cost Patients Work Group. The first paper focused on methods to identify high-need, high-cost patients. The third paper will offer guidelines to develop payer-provider relationships that promote sustainability of proven innovations.

The Task Force includes six of the nation’s top 15 health systems and four of the top 25 health insurers.  A full list of Task Force members – all committed to putting 75 percent of their business into value-based arrangements that focus on the Triple Aim of better health, better care and lower costs by 2020 – can be found at

About Health Care Transformation Task Force

Health Care Transformation Task Force is a unique collaboration of patients, payers, providers and purchasers working to lead a sweeping transformation of the health care system. By transitioning to value-based models that support the Triple Aim of better health, better care and lower costs, the Task Force is committed to accelerating the transformation to value in health care. To learn more, visit