Care Transformation Center Blog

Support high-risk patients with these underutilized services

Megan Clark and Cabell Jonas

Managing high-risk patients takes a whole team. The most successful systems are working across the organization to ensure care managers are accessing all of the resources available to them.

There are four areas to tap for collaboration.

Make medication management a priority

High-risk patients have complex medication needs, making a pharmacist an invaluable resource on the care management team. Pharmacists can provide prescription recommendations, help reduce the risk of medication errors, and educate patients.

At Cedars-Sinai Medical Group, a clinical pharmacist works directly with complex patients and offers additional support to providers managing patients with multiple medications post-discharge.

Address underlying behavioral health needs

Managing care for high-risk patients must incorporate behavioral health. Organizations should ensure that both providers and patients have access to the right level of support to address behavioral health needs.

In the Improving Mood - Promoting Access to Collaborative Treatment (IMPACT) program, a psychiatrist is available for consults and meets with the care team weekly to suggest treatment modifications. This led to a 15% decrease in inpatient medical costs, and 115 depression-free days.

Encourage appropriate palliative care, end-of-life care management

As difficult as these conversations can be, care management teams should be proactive about palliative or end-of-life care, facilitating these discussions with patients and supporting transitions to appropriate resources.

"We have a robust end-of-life program, so the transition is very natural. Our care coordinators often maintain the relationship through the next stage." - Joan Brueggeman, Clinical Manager

Gundersen Lutheran Health System developed a palliative care program to prioritize early care planning. The care managers consult with the palliative care team for planning advice. As appropriate, care managers also support transitions to the palliative care team.

Connect patients to non-clinical and community-based resources

Non-clinical factors are often just as important as clinical considerations in determining a care plan. The goal here is not to re-create existing resources, but to build awareness for existing community resources.

For more details, read our previous post profiling Health Leads and Integrated Health Partners. 

Learn More

For more details on these strategies—and other ways to manage high-risk patients—read our full research study.


  • 1 MassGeneral Care Management Program Medicare beneficiaries selected for CMS Medicare Care Management for High Cost Beneficiaries Demonstration.