The Commonwealth Fund have published a report reviewing evidence about care models designed to improve outcomes and reduce costs for patients with complex needs.
The report describes research about clinical care models or care management programs implemented by health care provider organisations to improve outcomes and reduce costs for high-need, high-cost patients.
Based on a review of literature that assesses the evidence on the impact and features of such care models or care management programs, the report identifies common attributes of effective models and programs, as well as barriers to their uptake.
It finds that successful models have several common attributes:
- Targeting patients likely to benefit from the intervention
- Comprehensively assessing patients’ risks and needs
- Relying on evidence-based care planning and patient monitoring
- Promoting patient and family engagement in self-care
- Coordinating care and communication among patients and providers
- Facilitating transitions from the hospital and referrals to community resources
- Providing appropriate care in accordance with patients’ preferences.
Educating patients and helping them manage their medications was also identified as a component of successful initiatives.
The report can be accessed on the Commonwealth Fund website here.