Focusing on Patients With Complex Medical Needs via Intense Care Management Shows Promise, AJMC® Researchers Say

“Super-utilizers,” meaning patients with complex health issues and frequent hospital visits, are becoming a focus of care management programs in an effort to improve patient outcomes. A study published in The American Journal of Managed Care®, and featured on our next Managed Care Cast podcast, found that Medicare fee-for-service patients in four states who fit this category and were enrolled in a high-intensity care management program had 37 percent fewer unplanned hospital readmissions.

CRANBURY, N.J.--(BUSINESS WIRE)-- “Super-utilizers,” or patients with complex health issues and frequent hospital visits, are becoming a focus of care management programs in an effort to improve patient outcomes. However, evidence on their effectiveness is slim. A study published in The American Journal of Managed Care® (AJMC®) found that Medicare fee-for-service patients in four states who fit this category and were enrolled in a high-intensity care management program had 37 percent fewer unplanned hospital readmissions than a matched comparison group.

Investigators from Mathematica Policy Research conducted an evaluation of a project by the Rutgers University Center for State Health Policy, which received a $14.3 million healthcare innovation award from the Center for Medicare and Medicaid Innovation to replicate a nationally known team-based care model in California, Colorado, Missouri, and Pennsylvania.

The care model was created by the Camden Coalition of Healthcare Providers, a nonprofit that uses interdisciplinary, community-based care management to focus on the social determinants of health (SDOH) in Camden, New Jersey.

While the healthcare providers in this study varied, they had one thing in common: The intense care management program aimed to improve the health of patients with complex needs, many of whom lived in poverty, including by improving their SDOH by connecting them to community resources.

“The Camden Coalition is very encouraged by these strong results, which come from four very different places across the country where local provider groups stood up complex care models tailored to their own communities,” said Kathleen Noonan, chief executive officer of the Camden Coalition. “We’re pleased to have had a part in the development of their interventions, and in the evolution of the complex care field. These findings show the promise of whole-person approaches to care management, and the importance of focusing on social factors that drive health outcomes.”

“Our work contributes to the body of evidence on how care management programs may improve patient outcomes,” said Dr. Purvi Sevak, senior researcher at Mathematica Policy Research. “Our findings on this adaptation of the Camden super-utilizer program provide insight into the ability to replicate program impacts in different settings. While these results are promising, this model will need further testing at larger scales before it is possible to make stronger conclusions about its impacts.”

The study was limited by its small sample size (149 participants), and the researchers noted that a larger, randomized controlled trial of the Camden model is underway. Regardless, the mobile interdisciplinary care team model shows promise for reducing all-cause admissions, ambulatory care–sensitive condition admissions, and Medicare parts A and B spending, the researchers wrote.

Listen to the next Managed Care Cast, featuring authors Dr. Purvi Sevak, senior researcher at Mathematica Policy Research, and Cara Stepanczuk, MPA, researcher in the health unit at Mathematica, where they will discuss the impact of these findings for those who care for patients with complex medical needs.

For more information, visit www.ajmc.com.

About The American Journal of Managed Care®

The American Journal of Managed Care® (AJMC®) is a peer-reviewed, Medline-indexed journal that keeps readers on the forefront of health policy by publishing research relevant to industry decision makers as they work to promote the efficient delivery of high-quality care. AJMC.com is the essential website for managed care professionals, distributing industry updates daily to leading stakeholders. Other titles in the AJMC® family include The American Journal of Accountable Care® and two evidence-based series, Evidence-Based Oncology™ and Evidence-Based Diabetes Management™. These comprehensive offerings bring together stakeholder views from payers, providers, policymakers and other industry leaders in managed care. To order reprints of articles appearing in AJMC® publications, please contact Gil Hernandez at 609-716-7777, ext. 139.

About the Camden Coalition of Healthcare Providers

The Camden Coalition of Healthcare Providers is a citywide coalition of over 35 hospitals, primary care providers, and community organizations working together to deliver better health care to vulnerable citizens in Camden, NJ. Founded by Dr. Jeffrey Brenner in 2002, the Coalition knits together a fragmented health care system for patients with complex needs and repeated, ineffective and expensive hospitalizations, using smart data and holistic, multi-disciplinary team care. We believe if we can deliver better care at lower cost here in Camden, it can be done for everyone, everywhere in America.

About Mathematica

Mathematica is the insight partner for public- and private-sector changemakers. Our 1,200+ experts are pioneers in their fields, continually reimagining the way the world gathers and uses evidence. We dive into urgent social challenges with rigor and objectivity to give our partners the clarity they need to see clearly and act quickly.

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AJMC^® Media Contact:

Alexandra Ventura, 609-716-7777, ext. 121

[email protected]



John Patricolo, 609-325-4630

[email protected]



Camden Coalition Media Contact

David Scholnick, 856-365-9510, ext. 2013

Source: The American Journal of Managed Care