The challenges of caring for high-need, high-cost patients have led increasingly to the use of specially trained complex care management (CCM) teams that identify and engage high-risk patients, assess their needs, and intervene rapidly to changes in their health status. These programs use a variety of approaches, but their common goal is to improve coordination of care and quality of life and reduce unnecessary use of services.
A critical step for CCM programs is to select and prioritize high-risk individuals for whom care management interventions might improve care and reduce costs. This report provides practical guidance on selecting such patients, based on approaches identified during in-depth interviews of leaders at 20 leading CCM programs. The research focuses on programs in which CCM teams work closely with primary care teams -- such programs are sometimes referred to as "primary-care integrated."