Leading the Way: Complex Care Management Program Overviews

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Nearly half of US residents live with cardiovascular disease, diabetes, or other chronic conditions. This proportion is projected to increase over the next decade, and the number of patients with more than one chronic condition is expected to grow in tandem. Health care providers face the challenge of coordinating care for these patients, who often require many different services.

This national scan of innovative and successful approaches to managing care for patients with complex, chronic conditions includes 19 programs:

General: A range of strategies is presented in these program overviews.

  • Aetna: Medicare Advantage Embedded Case Management Program
  • Brigham and Women’s Hospital: Care Management Program
  • Independent Health: Care Partners
  • Intermountain Healthcare and Oregon Health and Science University: Care Management Plus
  • Johns Hopkins University: Hospital at Home
  • Mount Sinai Medical Center-New York: Mount Sinai Visiting Doctors Program / Chelsea-Village House Calls Programs
  • Partners in Care Foundation: HomeMeds Program
  • Princeton HealthCare System: Partnerships for PIECE
  • Quality Improvement for Complex Chronic Conditions: CarePartner Program
  • Senior Services: Project Enhance / EnhanceWellness
  • Senior Whole Health: Complex Care Management Program
  • Summa Health / Ohio Department of Aging: PASSPORT Medicaid Waiver Program
  • Sutter Health: Sutter Care Coordination Program
  • University of Washington School of Medicine and Group Health Research Institute: TEAMcare

Technology-Based: Three programs use technology as a key component of care management.

  • Cook County Health and Hospitals System: Computer Assisted Quality of Life and Symptom Assessment of Complex Patients
  • University of Missouri: TigerPlace
  • Wenatchee Valley Medical Center: Health Buddy — Patient Telemonitoring Program

Regional: These programs are models for providers that operate across an extensive geographic area.

  • Adirondack Health Institute: Adirondack Region Medical Home Pilot
  • Providence Health Care and Group Health Cooperative: Tri-County Health / Health Share of Oregon

The overviews — one collection for each category — are available as Document Downloads.