Many pioneering programs have reduced avoidable utilization of care and lowered costs while improving health outcomes for adults with complex needs. The most promising models target high-risk populations and provide key elements of person-centered care, including individualized care plans, interdisciplinary care teams, active care coordination, and continuous information-sharing with providers and patients.
The Quick Reference Guide to Promising Care Models offers summary information on 28 programs for adults with complex needs, specifically:
- Target population and subpopulations served by the model
- Key features of the model associated with person-centered care
- Outcomes and impact
Although the evidence base is evolving, we know many existing care models meaningfully improve a person’s quality of life. It is important to continue testing promising care models in different settings, from the health care system to the home, and to develop better measures of person-centered outcomes on total cost of care. The resulting information will help guide the development of financially sustainable and scalable models of care for people with complex needs.
About The Quick Reference Guide
The guide was updated in January 2019 using the original version of the Quick Reference Guide developed in December 2016, data from a survey of promising care models conducted by the Center for Health Care Strategies for the Better Care Playbook’s State Map, and targeted literature searches.
Models were included if they targeted adults with complex needs, provided at least one element of person-centered care, and had strong, moderate, or promising evidence on at least one outcome related to quality, utilization, or cost. Links are provided under the Models and Outcomes columns for additional information and references. In some cases, the number of sites was obtained from sources other than those listed above, which are detailed in footnotes as applicable.
ACKNOWLEDGMENTS
The authors thank Meredith Brown and Jamie Ryan who helped to develop the original Quick Reference Guide in December 2016, as well as Allison Hamblin, senior vice president; Jim Lloyd, program officer; and Sarah Rabot, program analyst from the Center for Health Care Strategies for assistance collecting and verifying information for the guide.
Model |
Target population |
Population segments |
Elements of
|
No. of sites |
Outcomes |
Learn more |
|
Medicaid eligible high users of the emergency department |
|
|
2 |
A peer-reviewed analysis found participants in this “hotspotting” intervention had 28% fewer ED visits and 114% higher primary care utilization compared to controls (learn more). |
Roberta Capp, MD Assistant Professor of Emergency Medicine, University of Colorado School of Medicine
|
|
|
Medicare Advantage plan members in California, Nevada, Arizona, Virginia, Ohio, and Medicaid managed care plan members in Tennessee and Iowa |
|
|
56 |
The Medicare Advantage plan has shown, compared to the overall Medicare fee-for-service population, lower 30-day hospital readmission rates (13.8% vs. 19.6%) and shorter hospital length-of-stay (3.2 days vs. 5.6-day average) (learn more).
The Medicaid plan has shown 10%–17% fewer days in the hospital, 21%–22% fewer ED visits, and 23%–28% fewer specialist visits than other Medicaid managed care beneficiaries in the same area (learn more). |
Sachin H. Jain, MD, MBA President and CEO, CareMore Health System
|
|
|
Originally designed for age 65+ adults with multiple comorbidities such as diabetes, frailty, dementia, depression, and other mental health needs; the model has been adopted for nonelderly patients with complex needs |
|
|
~400 |
Randomized controlled trial (RCT) of the model showed 3.2% lower hospitalizations and, for patients with diabetes, 4.4% lower mortality compared to controls (learn more). |
David Dorr, MD, MS Professor and Vice Chair, Medical Informatics, Oregon Health Science University
|
|
|
Community-dwelling adults with at least one acute or chronic condition requiring posthospital care (excludes psychiatric conditions) |
|
|
8001 |
RCT showed intervention patients had significantly lower rehospitalization rates at 30 days and 90 days than control patients. Mean hospital costs were lower for intervention patients than control patients at 180 days (learn more).
Summary review shows intervention yields return on investment of 131% per year and annual savings of $2,311 per enrollee (learn more). |
Eric A. Coleman, MD, MPH Professor of Medicine and Head of the Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus
|
|
|
Adults with one or more chronic conditions |
|
|
n/a2 |
RCT of patients with chronic conditions found intervention group experienced fewer hospitalizations, shorter hospital stays, more energy, less fatigue, and greater improvement in self-reported health compared to controls (learn more).
National survey of 1,170 intervention participants in 17 states found significant reductions in ED visits (5%), hospitalizations (3%), and potential net savings of $364 per participant after accounting for cost of program (learn more). |
Coleen Travers, LCSW, LMSW Licensed Clinical Social Worker, Stanford Coordinated Care
|
|
|
Dual-eligible age 65+ adults enrolled in Senior Care Options Program (a Medicare Advantage Special Needs Plan in Massachusetts) and dual-eligibles age 64 and younger in Massachusetts One Care Program |
|
|
13 |
Unpublished data for Senior Care Options enrollees have found positive results including decreased hospital admissions, decreased hospital readmissions, and a decrease in overall expenses for acute care needs (learn more).
Results not yet available for OneCare. |
Christopher D. Palmieri President and CEO, Commonwealth Care Alliance
|
|
|
Community Aging in Place—Advancing Better Living for Elders (CAPABLE) |
Low-income people who need assistance with at least one activity of daily living like self-feeding or two instrumental activities of daily living like managing money |
|
|
17 |
Studies have shown a 67% decrease in average ADL problems (learn more), reduced readmissions (learn more), and 11% lower probability of having expenditures for health care services which contributed to average Medicaid savings of $867 per month per participant (learn more). In one study, 94% of intervention group participants thought program made life easier for them (learn more). |
Sarah Szanton, PhD, ANP, FAAN Professor, Johns Hopkins School of Nursing
|
|
Community Care Behavioral Health Organization: Behavioral Health Home Plus |
Individuals with serious mental illness |
|
|
52 |
A formal study indicated nearly 2-point overall increase in patient activation scores, 36% overall increase in primary and specialty care use, and decreased behavioral and medical inpatient use (learn more). |
Patricia Schake, MSW Senior Director of Program Innovations, Community Care Behavioral Health Organization
|
|
Frequent users of the emergency department |
|
|
5 |
A pre–post convenience sample study demonstrated 71% reduction in ED visits and 55% decline in hospital treatment costs among frequent users of the ED (learn more). |
Darin Neven, MS, MD President and Founder, Consistent Care Services
|
|
|
Likely high-users of emergency and inpatient care |
|
|
1 |
A study found this proactive intervention focused on patient engagement contributed to a 43% reduction in both ED visits and hospital days among enrollees and $839,892 in total direct cost savings over the first year (learn more). |
Marigny Manson Bratcher, RN Nursing Program Coordinator, Duke University Medical Center
|
|
|
Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care |
Low-income elderly with multiple diagnoses |
|
|
224 |
RCT of intervention in a Veterans Affairs Medical Center showed a 7.1% reduction in ED visits, 14.8% fewer 30-day readmissions, 37.9% fewer hospital admissions, 28.5% fewer total bed days of care, and lower costs (learn more). RCT in other settings showed similar reductions in ED visits and hospitalizations (learn more). |
Dawn Butler, MSW, JD Director, GRACE Training and Resource Center
|
|
Older adults with multiple chronic conditions who are at risk of high health expenditures in the next year |
|
|
8 |
Studies have shown intervention participants had twice greater odds of rating the quality of their chronic care highly (learn more) and 29.7% reduction in the use of home care compared to controls (learn more). Another study found physicians participating in Guided Care reported significantly increased satisfaction with family communication compared to controls (learn more). |
Cynthia Boyd, MD, MBA Professor, Johns Hopkins University School of Medicine
|
|
|
Chronically ill, older adults |
|
|
2 |
RCT of this care coordination and disease management intervention showed all-cause mortality reduced 22%–34% depending on risk group and duration (learn more).
Other research has shown reduced hospitalizations, ED visits, and Medicare costs after program fees for appropriately targeted higher-risk populations (learn more). |
Ken Coburn, MD, DrPH, FACP CEO and Medical Director, Health Quality Partners
|
|
|
Homeless veterans |
|
|
65 |
A number of detailed studies have found those participating in this comprehensive care and housing support intervention were significantly less likely to use ED (learn more) and cost on average $9,379 less per year compared to homeless veterans enrolled in traditional primary care services (learn more). |
Erin Johnson Supervisor, U.S. Department of Veteran Affairs
|
|
|
Older patients with a targeted acute illness that requires hospital-level care and who meet validated medical eligibility criteria and live within the designated geographic catchment area |
|
|
12 |
Studies have found 19% lower patient costs and overall greater patient satisfaction with intervention patients compared to similar inpatients (learn more). In addition, program has demonstrated reduced complications and greater patient and caregiver satisfaction (learn more). |
Bruce Leff, MD Professor, Johns Hopkins University School of Medicine
|
|
|
Older adults in a hospital setting with delirium or risk factors for delirium and/or functional decline |
|
|
2005 |
Multiple studies have found improved outcomes including 40% lower odds of developing delirium and 56 fewer days of delirium among those in intervention group that received personalized, comprehensive care (learn more). One test hospital site saved approximately $2,181 per case by preventing delirium (learn more). |
Sarah Gartaganis, LCSW, MPH Project Director, Aging Brain Center, Harvard University
|
|
|
Improving Mood – Promoting Access to Collaborative Treatment (IMPACT) |
Individuals with behavioral health needs |
|
|
~1,0006 |
RCT of adults age 60+ with major depression, dysthymic disorder, or both, found after 12 months, about half of IMPACT patients had 50% or greater reduction in depressive symptoms from baseline assessment compared to 19% of patients receiving usual primary care (learn more).
Over a four-year period, total health care costs for IMPACT patients were approximately $3,363 lower per patient on average than those of patients receiving usual primary care, even after accounting for cost of providing intervention (learn more). |
Jürgen Unützer, MD, MPH, MA Founder, AIMS Center
|
|
Medicare beneficiaries with multiple chronic conditions and functional limitations |
|
|
147 |
Enrollees had fewer hospital readmissions within 30 days and lower use of inpatient hospital and ED services for such conditions as diabetes, high blood pressure, asthma, pneumonia, and urinary tract infection (learn more). In addition, program produced savings for Medicare (learn more). |
Brent Feorene Executive Director, American Academy of Home Care Medicine
|
|
|
Residents of long-term care facilities |
|
|
264 |
Among the 25 nursing homes that completed the project, there was a 17% reduction in all-cause hospitalizations (learn more). |
Joseph Ouslander, MD Chair of the Department of Integrated Medical Science and Senior Associate Dean of Geriatric Programs, Florida Atlantic University
|
|
|
Adults and the elderly with complex medical and social needs |
|
|
1 |
Evaluation of this intervention, which emphasizes partnerships with community organizations, found reductions in hospitalizations and ED visits for Medicare and Medicaid patients and decreased total cost of care (learn more). |
Melissa Sherry, MPH Director, Population Health Innovation and Transformation, Johns Hopkins HealthCare
|
|
|
People with dementia and other memory disorders |
|
|
1 |
Studies have found participants in this home-based care coordination intervention saw delay of nursing home entry, better self-reported quality of life, and fewer hours of direct care per week compared to controls (learn more). |
Constantine G. Lyketsos, MD Elizabeth Plank Althouse Professor, Department of Psychiatry, Johns Hopkins University School of Medicine
|
|
|
The most seriously ill and those at end of life |
|
|
~1,7448 |
Palliative care hospital patients discharged alive had adjusted net savings of $1,696 in direct costs per admission and $279 in direct costs per day, including significant reductions in laboratory and intensive care unit costs compared with usual care patients (learn more). In addition, palliative care and hospice services have been shown to reduce depression, pain, and other symptoms; improve patient and family satisfaction; and may even prolong life compared to usual care (learn more). |
Diane Meier, MD, FACP Director, Center to Advance Palliative Care (CAPC)
|
|
|
Individuals who are high-cost and/or have complex conditions |
|
|
1 |
An independent evaluation of this care coordination effort found that after three years the intervention group, compared to controls, had rates 20% lower for hospital admissions and 13% lower for ED visits. Program achieved 7% annual net savings, after accounting for intervention costs (learn more). |
Eric Weil, MD Medical Director, Mass General Care Management Program
|
|
|
Age 55+ adults who have Medicare and/or Medicaid, have chronic conditions and/or functional and cognitive impairments, live in service area of local PACE organization, and are Medicaid-certified as eligible for nursing home level care |
|
|
233 |
Recent review of literature found PACE enrollees experienced fewer hospitalizations, but more nursing home admissions; better quality for certain aspects of care, such as pain management (learn more). Subsequent study found PACE enrollees had 31% lower risk of long-term nursing home admission compared to home- and community-based waiver participants (learn more).
PACE appears to be cost-neutral to Medicare and may have increased costs for Medicaid; more research is needed to reflect current payment arrangements (learn more). |
Robert Greenwood, MA Senior Vice President of Public Affairs, National PACE Association
|
|
|
Seniors and individuals with special needs, throughout the state of Vermont |
|
|
155 9 |
An independent evaluation found that participants had improvements in self-reported physical and mental health status and statistically significant lower rates of growth in Medicare expenditures (by $1,227 per beneficiary per year) compared to controls (learn more). |
Molly Dugan, MPA Director, Cathedral Square Corporation Support and Services at Home
|
|
|
The top 10% highest-cost, highest-need homeless individuals in Los Angeles County |
|
|
4 |
A program evaluation of this housing intervention found average annual health care and public sector cost reductions of $54,106 per person, per year, 71% decrease in ED visits, and 84% decrease in hospital admissions (learn more). |
Susan Lee, MBA Senior Program Manager, Corporation for Supportive Housing
|
|
|
Hospitalized, high-risk adults with chronic conditions |
|
|
342 |
RCT of this time-limited coordination intervention found that, one year after hospital discharge, intervention group had fewer readmissions and lower mean total costs ($7,636 vs. $12,481). Intervention group also experienced short-term improvements in overall quality of life and patient satisfaction (learn more). |
Karen Hirschman, PhD, MSW Research Associate Professor, University of Pennsylvania
|
|
|
Virginia Commonwealth University Health System Complex Care Clinic |
Uninsured individuals with complex medical and social needs |
|
|
1 |
Internal evaluation found Complex Care Clinic — which addresses holistic, nonmedical needs of patients — achieved 44% decline in inpatient admission, 38% decrease in ED use, and 49% reduction in total hospital costs in first year. A formal external evaluation is currently being conducted (learn more). |
Kimberly Lewis, M.Ed, MCHES Director of Outreach and Administration, Virginia Commonwealth University Health System
|
1 Number of sites provided by Eric Coleman, principal investigator of Care Transitions Intervention, in January 2019.
2 Chronic Disease Self-Management Program is widespread; there is no numeric estimate of sites available.
3 The Commonwealth Care Alliance operates in sites throughout the state of Massachusetts.
4 The GRACE model has been replicated nationally, but only 22 sites are operated by GRACE Team Care.
5 Number of sites obtained from the Hospital Elder Life Program website.
6 Number of sites provided by Jürgen Unützer, founder of the AIMS Center, in November 2018.
7 Number of sites obtained from the Independence at Home website.
8 Number of sites obtained from the Center to Advance Palliative Care website.
9 Number of sites obtained from the Support and Services at Home website.