Brent C. Williams, MD, MPH

has been adopted by many health systems to improve care and decrease costs through coordination of care across levels. At our academic medical center, several care management programs were developed under separate management units, including an inpatient-based program for all patients and an outpatient-based program for complex, high-utilizing patients. To bridge administrative silos between programs, we examined longitudinal care experiences of hospitalized complex patients to identify process and communication gaps, drive organizational change, and improve care. 

 This descriptive study analyzed the care experiences of 17 high-utilizing patients within the authors’ health system.

 Chart audits were conducted for 17 high-utilizing patients with 30-day hospital readmissions during 2013. Clinical and social characteristics were reviewed for patterns of care potentially driving readmissions. 

 Patients had heterogeneous social factors and medical, psychological, and cognitive conditions. Care management interventions apparently associated with improvements in health and reductions in hospitalization utilization

included movement to supervised living, depression treatment, and achievement of sobriety. Monthly case management meetings were restructured to include inpatient, outpatient, ambulatory care, and emergency department care managers to improve communication and process. During 2014 and 2015, hospital readmission rates were overall unchanged compared with base year 2013 among a comparable cohort of high-utilizing patients. 

Joint review of clinical characteristics and longitudinal care experiences of high-utilizing, complex patients facilitated movement of historically siloed care management programs from their focus along administrative lines to a longitudinal, patient-centered focus. Decreasing readmission rates among complex patients may require direct linkages with social, mental health, and substance use services outside the healthcare system and improved discharge planning.

To bridge administrative silos between care management programs, we examined longitudinal care experiences of hospitalized complex patients to identify process and communication gaps, drive organizational change, and improve care. 

Charts of 17 high-utilizing patients with heterogeneous medical and psychological conditions were reviewed for clinical and social characteristics and patterns of care potentially driving readmissions. 

Care management interventions apparently associated with improvements in health and reductions in hospitalization utilization included movement to supervised living, depression treatment, and achievement of sobriety. 

We are restructuring our monthly case management meetings to ensure simultaneous participation of case managers from inpatient, outpatient, ambulatory care, and emergency department service lines to eliminate communication and process gaps and better serve the wide range of clinical and social service needs of complex high-utilizing patients.

Thirty-day hospital readmission rates are high among individuals with complex medical and psychosocial needs.

 Although findings of randomized controlled trials (RCTs) have shown care transition interventions can reduce hospital readmissions in older adults

 populations with multiple comorbidities and mental illness or substance abuse present special challenges. Some programs report success in improving services for this population,

 but we identified no RCTs showing reductions in readmission. The purpose of this paper is to describe the clinical characteristics and health service needs of readmitted patients with complex medical and psychosocial needs, with implications for linkages between inpatient and outpatient care management programs.

At our academic medical center, a number of care management programs focused on diseases or settings were developed to improve care transitions and reduce readmissions. Most evolved through separate administrative units without establishing communication or collaboration processes across units or levels of care. As these programs grew, one vexing gap in coordination occurred between inpatient and outpatient programs. This was highlighted in 2010 when changes to inpatient discharge planning were undertaken and renamed care management without coordinating with the outpatient care managers caring for many of the most complex patients. Therefore, we wished to build coordinated care management protocols between inpatient care management nurses and social workers and the outpatient care management social workers working with complex patients. This program, our Complex Care Management Program (CCMP), is primarily staffed by social workers due to patients’ behavioral and socioeconomic needs. To facilitate this process, we applied the Lean process from Toyota,

 which asserts that problems are best analyzed and addressed by the individuals closest to the data from the point of delivery. Specifically, we undertook a patient-level analysis of a cohort of complex patients with 30-day readmissions.

The CCMP provides care management to individuals with significant challenges in several of 5 domains based on the 

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

 classification system: major psychiatric conditions, behavioral and substance use disorders, active medical conditions, lack of social support, and inadequate physical resources (eg, precarious housing or food, limited transportation, or multiple socioeconomic barriers). At the time of this study in 2013, patients were enrolled in CCMP primarily through record review of Medicaid- and Medicare-enrolled and uninsured patients discharged from inpatient and emergency department (ED) services. A complex care manager conducted a phone assessment of each candidate patient, using questions covering the 5 domains with additional tailored follow-up questions, such as their understanding of and ability to obtain medications and keep appointments.

 Most received only this phone call, but during the study period, approximately 10% to 15% of patients assessed were identified as complex based on care managers’ qualitative judgment—usually indicating challenges in at least 3 of the 5 domains&mdash;and, if the patient was not known to CCMP care managers, were enrolled for ongoing care management. Incorporating key elements of successful care management programs for complex patients, CCMP care managers coordinate services for patients, accompany them to primary care and specialty appointments,

 and help to identify and reduce socioeconomic barriers to treatment.

 The usual caseload of complex patients per care manager is 25 to 35 patients.

 The CCMP serves approximately 450 patients annually.

We conducted a descriptive longitudinal analysis of patient experiences of a consecutive cohort of complex patients across levels of care at our institution. Seventeen CCMP patients with 1 or more 30-day readmissions during the first 3 quarters of 2013 were audited, including all with 30-day readmissions in 2 (n = 7) or 3 (n = 1) of the first 3 quarters. In addition, 7 patients with at least 1 readmission from the third quarter (the most recent data available) and 1 patient from each of the previous 2 quarters were audited (n = 9). Most were readmitted multiple times during the study period.

A nurse practitioner experienced in working with similar populations but unassociated with the medical center analyzed the data, identifying patients’ clinical conditions, presenting complaints at each hospitalization, types of healthcare professionals caring for the patient, and services provided during and between hospitalizations. Clinical judgment was used to identify factors potentially influencing readmission. Factors were qualitatively organized in categories mirroring the 5 domains used as enrollment criteria for CCMP. 

Patients ranged in age from 18 to 61 years; 7 were women and 10 were men. All but 1 had income below the federal poverty line, and most had Medicaid or Medicare or were uninsured. All patients had 2 or more chronic medical problems, multiple socioeconomic barriers, and/or were nonadherent to treatment. Many used food assistance programs and had limited social support, strained family relationships, and transportation problems (sometimes complicated by assistive devices, such as walkers). Several patients lived in group homes; 8 had precarious housing situations (

). Frequent housing changes complicated patient management and follow-up for medical and psychological conditions.

The most common chronic medical diagnoses were diabetes, hypertension, angina, chronic obstructive pulmonary disease (COPD), end-stage renal disease, and congestive heart failure. Two patients died during the 6-month audit period as a result of medical complications. Inpatient admissions over the study period ranged from 2 to 5 per patient (mean = 3.3). Common admission diagnoses were alcohol or substance toxicity/withdrawal, respiratory disease (asthma/COPD), chest pain, and psychological conditions (depression, suicidality, and psychosis). With the exception of alcohol/substance use—related admissions, readmissions were often for a different diagnosis than the previous admission, and no simple pattern emerged. 

Sixteen patients had psychiatric or psychological conditions; 1 had cognitive impairment. The most common psychological condition was depression, followed by anxiety, schizophrenia, and bipolar disorder. These conditions sometimes complicated efforts to manage medical conditions. In 2 patients, hallucinations and psychiatric medication adjustments caused behavioral changes that complicated self-management and access to healthcare. In others, depression or anxiety interfered with the ability to manage their conditions but was not considered severe enough to justify intervention by county Community Mental Health psychiatric providers, resulting in treatment delay. In another case, a patient was eligible for a program in which his psychiatric medication was monitored; however, no medication monitoring was available for his medical condition and he was re-hospitalized for that condition. 

Eight patients had substance use disorders, with alcohol dependence being the most common. Most readmissions in this group were related to substance use. Two were lost to follow-up during the study period.

Care Coordination Gaps and Institutional Response

Patients accessed health, behavioral, and social services at the community level, as well as multiple levels within the health system, and communication gaps between these services further challenged their care. In some cases, these challenges appeared to be factors in readmission, either through missed communication or the inability to effectively treat the patient’s medical or psychological conditions. In addition to primary care, emergency, and inpatient services, most patients saw 1 or more medical specialists and used community services related to housing, transportation, food, medications, health insurance, or mental health. 

One important challenge was that the electronic health records (EHRs) used in the community, outpatient, and inpatient services were not accessible by other agencies or different levels in the health system. Although CCMP personnel had access to health system records, health system personnel did not have access to CCMP records and neither group had access to community service records, possibly contributing to missed communication between levels of care. In 2 patients transferred to skilled nursing facilities, for example, medications for chronic medical/psychiatric conditions were not given, leading to 1 readmission and 1 loss to follow-up. In others, late or incomplete communication about laboratory results, medication dosages, or specialty follow-up preceded readmission. In addition, no system existed to communicate patient hospitalizations to CCMP staff and inpatient care managers were not always aware of CCMP resources. 

Identifying and acting on these communication challenges offered an early way for the health system to respond and potentially reduce readmissions. Administrators and care managers from the inpatient and CCMP programs reviewed the care experiences and communication gaps described in the audit at meetings throughout 2014. Timely communication among the patient, CCMP, and healthcare personnel was identified as a critical need related to readmission and coordination of posthospital services and referrals. As a result, program reform shifted toward improving communication, and patient-specific care planning was initiated between the inpatient care managers and the CCMP case managers who coordinated posthospital services. 

In early 2015, monthly meetings between inpatient care managers and CCMP care managers grew to include primary care—based care managers. Through most of 2015, meetings focused on communication and documentation protocols to enhance the visibility of care planning notes among inpatient, CCMP, and outpatient care managers, for example, by creating a new, more recognizable label for EHR encounters (eg, “complex care management” rather than the more generic “telephone note”). Early recognition of CCMP patients by inpatient care managers was improved through use of a flagging system in the EHR that indicated the patient’s enrollment in the CCMP and contact information for the CCMP care manager, allowing them to be invited to inpatient care planning meetings. In 2016, outpatient social workers began to participate in these care planning meetings. Bolstered by relationships established at these meetings, joint assessment and care planning are now routine and referrals from inpatient care managers to those from the CCMP have increased. The value of the CCMP in behavioral management planning and bridging between inpatient settings and primary care also motivated increased communication between inpatient and ED care managers and CCMP; these groups now meet regularly for patient care planning and process improvement. Use of a consistent EHR across all levels of care in the health system has also improved communication. 

In addition to communication within the health system, communication is critical between the health system care management programs and community services providing patients with ongoing treatment or safer hospital transitions. Although incompatible EHRs remain, it was clear that case managers in both the health system and community worked to identify services relevant to patients’ physical and psychological conditions. In some cases, medications or treatments were obtained after substantial communication with insurance companies, specialty care providers, or pharmacies. In others, identifying relevant nonmedical community services improved patients’ self-management of their chronic conditions. For example, 2 patients improved after low-cost counseling was identified and provided for depression and anxiety, 2 after movement to group homes, and 1 after becoming sober. Regular meetings are also held among CCMP personnel and community agencies.

Improving care planning around behavioral conditions is recognized as a priority but has been more difficult to address. Barriers include the historical lack of involvement by Community Mental Health providers when patients undergo a medical admission, even when care of the medical condition is complicated by the patient’s psychological condition. A work group including University of Michigan Psychiatry, the CCMP, inpatient care management, and Community Mental Health is being convened to facilitate communication among these settings while patients are in the ED or inpatient services. 

Despite improvements in early recognition, patient-specific root-cause analysis, and coordinated care planning, 30-day hospital readmission rates for all hospitalizations among CCMP clients have been relatively stable over time (

). Patient-specific readmission rates showed similar results (not shown). 

We undertook a patient-centered approach to begin to develop process solutions to reduce readmissions and support patients as they transition from inpatient to community settings. We used a readily available resource, longitudinal patient records, to examine patient experiences across levels of care and community services. Coordination gaps identified were used to develop improved communication processes among the multiple settings providing services to this population. Other factors contributing to readmissions were varied and included the complexity and severity of medical conditions, psychological and socioeconomic conditions that complicated disease management and care access, and substance use. This is consistent with prior work finding that lack of social support or resources, a history of substance abuse and/or mental illness, and difficulty obtaining medication or transportation impacted posthospital transitions of adults,

Several factors may explain the lack of effect on hospital readmission rates among CCMP patients. Overall, the portion of preventable hospital costs among high-risk populations has been estimated at just 6%.

 In addition, studies demonstrating a relationship between effective discharge planning and decreased readmission rates have largely not been conducted in this population.

 Decreasing avoidable hospitalizations in this population will likely require larger system reforms that address psychosocial determinants of health, the supply of behavioral health providers, and improved coordination of social service organizations with primary care. 

Although the system modifications we have begun have not resulted in measurable reductions in readmission rates, important changes have occurred. By using a review of patient experiences as a starting point rather than administrative protocols, new and productive conversations across units occurred. Previously siloed care managers in inpatient and ED settings now meet regularly with outpatient care managers to coordinate care for individual patients. Care management documentation protocols have been shared and made more visible in the EHR across units. Perhaps most importantly, working relationships among staff and managers from different administrative units have developed, fostering interest in continuing to find new ways to promote patient-centered, rather than unit-centered, care management at all levels, including care managers, program management, and senior leadership.

Only qualitative analysis was conducted; future research should include quantitative analysis of other factors such as length of stay and cost. In addition, the sample size was small, limiting generalizability. Finally, only 3 quarters were examined. However, consistent themes emerged across patients, suggesting that relevant factors had been identified for this population.

Effective care management programs for populations with medical, psychological, and social issues require collaboration across levels and disciplines, particularly with mental health and substance use providers,

 identification of patients at high risk of readmission,

 involvement of interdisciplinary teams in ongoing patient care,

 and building of trusting relationships between patients and care providers.

 However, development of horizontal organizational reforms that require collaboration across administrative units can be challenging in organizations where these units have historically operated independently. Using actual patients’ longitudinal experiences across inpatient and outpatient settings can help break down barriers to collaboration and joint planning, and foster trust and cultural transformation to promote further reform.

 University of Michigan (NG, CD, BCW), Ann Arbor, MI; Complex Care Management Program, University of Michigan (DF, BCW), Ann Arbor, MI.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Articles

The authors audited a series of complex patients’ records longitudinally across their institution’s existing care management programs to improve the coordinated functioning of these programs.

Improving Care Transitions: Complex High-Utilizing Patient Experiences Guide Reform

Estimates of total cost savings from care management in randomized trials are consistently low or none, in contrast to many current explicit or implied claims to the contrary. Therefore, it can be observed that:

		Much of the current literature and promotional materials based on nonrandomized studies dramatically overestimates total cost savings from care management for high-utilizing patients.

		Healthcare organizations implementing care management programs should expect low or no total cost savings.

		Care management programs whose objectives include lowering total costs should adopt practices of demonstrated effectiveness from randomized trials when available.

		Funders and researchers should promote randomized trials of care management for high-cost patients.

The disproportionate distribution of healthcare spending is well described and striking, with 5% of the population accounting for 50% of healthcare costs, and the most costly 1% accounting for 28% of the total.

Among patients with high healthcare costs, care management is widely recommended to both improve quality and reduce costs—a significant portion of which is believed to be unnecessary or avoidable. Although a variety of care management models exist, models focusing on high utilizers generally include a mechanism for identifying high-utilizing, high-need patients, and center on a multidisciplinary team of healthcare providers to address a complex interacting set of medical, psychological, behavioral, and social needs. Often led by a primary care manager, caseloads are usually relatively low, though they vary widely across models. Types of high-utilizing patients for whom intense care management is being directed or advocated include dual Medicare and Medicaid enrollees (“dual eligibles”),

 emergency department (ED) high utilizers,

and patients at high risk of hospital readmission.

Interest and investment in care management for high utilizers has exploded in recent years, with large demonstration trials by Medicare, CMS Innovations, and the Robert Wood Johnson Foundation.

This interest has been fueled in part by reports of dramatic cost savings from intensive care management programs for high utilizers. For example, as reported in a 2013 informational bulletin from the Centers for Medicaid and Children’s Health Insurance Program Services: “Cooper University Hospital in New Jersey was awarded $2.8 million to expand the Camden Coalition super-utilizer program to serve over 1200 patents with an estimated 3-year cost savings of $6.2 million. Rutgers, the State University of New Jersey, was awarded $14.4 million to test community-based super-utilizer models led by safety net provider organizations in Pennsylvania, Colorado, Missouri, and California, with an estimated 3-year cost savings of $67.7 million.”

Critical examination of the reports reveals, however, that the vast majority of studies describing substantial cost savings are not randomized trials; most often, they compare the costs of a single cohort before and after entering care management, or compare the costs of an intervention group with an arguably similar contemporaneous group. Among randomized trials, the picture is significantly different, with the effects of care management for high-utilizing patients on total costs demonstrated as limited or nonexistent. The sharp contrast between estimates of cost savings from randomized and nonrandomized trials has been remarkably underemphasized in the many publications and program promotions recommending “best practices” for high-utilizing patients.

A recent example illustrates the point well: in a review for The Commonwealth Fund by Hong and colleagues identifying best practices in care management for high-cost patients, care management practices from 18 models that demonstrated reduced costs and/or improved quality were described—4 of which were based on randomized trials.6 Among the 14 programs based on nonrandomized trials, reductions in costs of care by as much as 56% were reported. Even among the 4 randomized trials, total cost savings were described in the main tables and text of the report. However, in each randomized trial, cost savings were from selected subgroups only. In fact, in 3 of those 4 trials, total costs were not statistically significantly reduced (when including all patients),

 and in the fourth, only 1 out of 15 programs in a multi-site demonstration project showed sustainable total cost savings.

The introductory section of that same Commonwealth Fund report by Hong and colleagues includes the admission that “There is scant evidence of the effectiveness of primary care-integrated complex care management in reducing overall healthcare costs,” but the implications or reasons are not emphasized.

 and media reports12 of care management programs for high utilizers usually state or strongly imply that they lead to total cost savings. In contrast, studies focusing mainly on results from randomized trials have consistently found that in these trials, care management for high-risk groups has limited or no effect on the total costs of care.

 While this finding is not new, its underemphasis in descriptions of care management programs is striking.

Of the numerous potential reasons for the limited effects of care management for high-risk individuals on total costs, 3 will be highlighted here. First, most high-utilizing patients are transient high utilizers, as medical or mental health conditions or external circumstances combine to create a crisis point resulting in multiple ED or hospital admissions. In most, but not all cases, crisis conditions resolve after a few weeks or months regardless of programmatic interventions that have been mounted in the interim. While statisticians dryly refer to this phenomenon as regression to the mean, from a human-services point of view it is a powerful effect. Care management programs claim credit for the decline in costs of a targeted group of high utilizers over time, while in fact, during the observation period, a new group of patients assumes the position of high utilizers. Second, high utilizers are clinically heterogeneous, and they vary in responsiveness to interventions. High utilizers include persons experiencing catastrophic illnesses, the late stages of terminal diseases, or changes in social or support circumstances (eg, loss of housing, aggravation of a substance use disorder, loss of insurance) that result in transient loss of access to healthcare, as well as the relatively small cohort of longer-term high utilizers. Given this reality, tailoring the configuration and provider skill set for programs targeting highutilizing patients is challenging. Finally, in many cases, appropriate care management leads to increased use of hospital or other healthcare, as previously unrecognized or neglected problems are identified and treated.

While it can be somewhat difficult to discern exactly why it is so challenging to lower total healthcare costs among high utilizers, even more befuddling are the reasons this fact is so underplayed in current discussions and in the development of care management programs for high utilizers. My own speculation is that it is the result of the confluence of at least 5 forces. First, the central priority of lowering total healthcare costs now has traction across a wide range of constituents—including government and private payers, as well as providers&mdash;so any promising solution seems attractive. Second, new reimbursement schemes that reward systems for lowering total costs (eg, accountable care organizations) have made development of nonbilling care management programs more financially viable. Third, the dramatically disproportionate healthcare costs of a small portion of patients presents a psychologically compelling case that targeting these few patients should make a difference in overall costs. Fourth, powerful success stories among some patients from innovative programs that focus on sound principles (eg, relationship-centered care, care that accounts for the social determinants of health) lead to discussions among like-minded individuals to develop increasingly better programs to help many of our nation’s most vulnerable persons. Finally, these 4 factors combine to create a market opportunity for companies providing care management, who are motivated to selectively emphasize evidence favoring the cost-reducing effects of care management programs from nonrandomized trials.

Moving forward, several lessons seem compelling. Funders should support randomized trials where possible, and facilitate dissemination of the overall results as well as results from negative trials among payers and providers. While fraught with challenges, randomized trials among vulnerable populations are possible, and they should be encouraged by large funding agencies.

Among providers building or expanding care management programs that target high utilizers, the results of randomized controlled trials should weigh most heavily in estimating the effects of interventions on total costs of healthcare at their institutions. Second in line should be nonrandomized studies that measure total population costs over time rather than just costs of intervention and nonrandom comparison groups.

Also, in developing budgets for organizations that are implementing care management programs modeled after programs tested in nonrandomized trials, providers should expect effects on total costs to be either nonexistent or significantly smaller than those reported.

For care management programs focusing on high-utilizing patients, it is crucial to select patients with longterm utilization patterns that are driven by the factors most conducive to change. Given the very limited direct evidence suggesting how to accomplish this, care management programs are best served by being kept small and focused on the highest-need patients, who may not necessarily be current high utilizers. This will run counter to the current tendency to expand care management to broader and broader populations, and it will have the effect of excluding from enrollment some patients who appear deserving to referring clinicians and care managers. Interventions chosen should be based on best evidence of best practices, including those from nonrandomized trials, since to date these reports represent our best guess about practices most likely to lower total costs of care.

Discussions and reports describing nonrandomized trials should be placed in the context of the results, strengths, and limitations of randomized trials, as with any other medical intervention. This should lead to explicit analyses of how, and by how much, the reported trial may overestimate effects on total costs.

Care management models implemented by health systems, providers, and payers should be better informed by the last 20 years of evidence related to care management and less driven by uninformed promises of quick savings and simple solutions. As they do so, effects on total healthcare costs should be expected to be modest. By keeping this fact in mind, care management can be most effectively implemented, and its effects measured, to improve health, avoid decline, and limit avoidable costs among our most vulnerable patients.

Dr Williams wishes to thank Larry McMahon for helpful comments and suggestions on the manuscript.

 Department of Internal Medicine, University of Michigan, and University of Michigan Complex Care Management Program, Ann Arbor, MI.

 Dr Williams serves as medical director for the University of Michigan Complex Care Management Program. Authorship Information: Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content; administrative, technical, or logistic support.

Brent C. Williams, MD, MPH, University of Michigan, 2800 Plymouth Rd, North Campus Research Complex, Bldg 16, Rm 447E, Ann Arbor, MI 48109-2800. E-mail: 

1. Cohen SB; Agency for Healthcare Research and Quality. The concentration of health care expenditures and related expenses for costly medical conditions, 2009. AHRQ Statistical Brief #359. 

http://meps.ahrq.gov/mepsweb/data_files/publications/st359/stat359.pdf

. Published February 2012. Accessed December 14, 2014.

2. Coughlin TA, Waidmann TA, Phadera L. Among dual eligibles, identifying the highest-cost individuals could help in crafting more targeted and effective responses. 

3. Putre L; Aligning Forces for Quality; Robert Wood Johnson Foundation. Caring for health care’s costliest patients: communities find ways to identify and treat ER ‘super-utilizers.’ Aligning Forces for Quality website. 

http://forces4quality.org/caring-health-cares-costliest-patients

. Published January 2014. Accessed December 14, 2014.

4. Mann C; Center for Medicaid and Children’s Health Insurance Program Services (CMCS). CMCS informational bulletin: targeting Medicaid super-utilizers to decrease costs and improve quality. Medicaid.gov website. 

http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-07-24-2013.pdf

. Published July 24, 2013. Accessed December 14, 2014.

5. Silow-Carroll S, Edwards JN, Lashbrook A; The Commonwealth Fund. Synthesis report—reducing hospital readmissions: lessons from top-performing hospitals. The Commonwealth Fund website. 

http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Apr/1473_SilowCarroll_readmissions_synthesis_web_version.pdf

. Published April 2011. Accessed December 14, 2014.

6. Hong CS, Siegel AL, Ferris TG. Caring for high-need, high-cost patients: what makes for a successful care management program? 

7. Counsell S, Callahan CM, Clark DO, et al. Geriatric care management for low-income seniors: a randomized controlled trial. 

8. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. 

9. Leff B, Reider L, Frick KD, et al. Guided care and the costs of complex healthcare: a preliminary report. 

10. Bell J, Mancuso D, Krupski T, et al; Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations; University of Washington at Harborview Medical Center. A randomized controlled trial of King County Care Partners’ Rethinking Care Intervention: health and social outcomes up to two years post-randomization. Center for Health Care Strategies, Inc website. 

http://www.chcs.org/media/RTC_Evaluation_TECHNICAL_REPORT_FINAL_3_15_12a.pdf

. Published March 15, 2012. Accessed December 14, 2014.

11. Shore J, Peikes D, Peterson G, Gerolamo A, Brown R; Mathematica Policy Research. Fourth report to Congress on the evaluation of the Medicare Coordinated Care Demonstration. CMS website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/Schore_Fourth_Eval_MCCD_March_2011.pdf. Published March 2011. Accessed December 14, 2014.

12. Levin-Epstein M. Programs for high-need patients: what makes the good ones good? Managed Care website. 

http://www.managedcaremag.com/archives/2014/12/programs-high-need-patients-whatmakes-good-ones-good

. Published December 2014. Accessed December 28, 2014.

13. Hickam DH, Weiss JW, Guise J-M, et al; Oregon Evidence-based Practice Center; Agency for Healthcare Research and Quality. Outpatient case management for adults with medical illness and complex care needs. Report 13-EHC031-EF. Comparative Effectiveness Reviews, No. 99. 

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0051452/

. Published January 2013. Accessed December 14, 2014.

14. Phillips RL Jr, Han M, Petterson SM, Makaroff LA, Liaw WR. Cost, utilization, and quality of care: an evaluation of Illinois’ Medicaid primary care case management program. 

15. Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. 

Explanations for, and implications of, the sharp contrast between the results of randomized and nonrandomized trials of care management to lower total healthcare costs are examined.

Brent C. Williams, MD, MPH

Articles

Improving Care Transitions: Complex High-Utilizing Patient Experiences Guide Reform

Limited Effects of Care Management for High Utilizers on Total Healthcare Costs