While much is known about how to care for patients with single chronic conditions — such as diabetes or heart disease — there is less consensus about the best way to manage high-cost patients with multiple and complex chronic conditions.
Working with the California Quality Collaborative, in 2011 CHCF created the Complex Care Management Action Community, a yearlong program that enabled eight California-based organizations with demonstrated experience caring for medically complex patients to join together to share and test improvements for producing better health outcomes at lower cost.
Participants gained access to:
- California and national experts with knowledge and expertise in managing high-cost, medically complex populations
- Facilitated peer learning
- Expert faculty consultation and coaching to help test changes in care management
The following organizations participated:
- Bristol Park Medical Group
- CalOptima
- Central California Alliance for Health
- HealthCare Partners
- High Desert Medical Group
- Humboldt Del Norte IPA/Foundation
- PrimeCare
- St. Joseph Heritage Medical Group
Over the course of the year, Action Community members participated in shared learning via three all-day, in-person sessions, along with teleconference calls that supplemented learning and information exchange.
The Complex Care Management Toolkit, available as a Document Download, summarizes ideas to improve an existing complex care management program or implement a new one for individuals with multiple chronic conditions, limited functional status, and psychosocial needs. It includes resources that can be adapted as you build or test changes for your program.
More information and the program materials, including meeting presentations, action plans, and final reports with lessons learned, are available on the California Quality Collaborative website through the External Link below.