Care Transformation Center Blog

75% of our readers plan to hire a high-risk care manager

Cabell Jonas

Since my last post, which clarified the differences between a health coach and a care manager, nearly 75% of readers told us they plan to hire a high-risk care manager to meet contract goals.

To get tips for deploying this new staff member, log in to read our case study on Massachusetts General Hospital—an organization that successfully used a high-risk outpatient care manager to reduce utilization while maintaining high-quality care for 2,500 of its highest-risk, costliest Medicare patients.

What your care manager's responsibilities should look like

In contrast to the health coach, who manages the general preventative and chronic care of entire patient panels1, the high-risk care manager only works with a chosen high-risk subset—typically the top 5-10%2. The high-risk patients served through this model typically have multiple chronic illnesses, complex behavioral health comorbidities, and may have significant non-clinical needs.

The high-risk outpatient care manager’s day-to-day activities include:

  • Coordinating care along the continuum
  • Navigating patients to several providers
  • Providing support to meet health goals
  • Activating these patients to improve self-management

Effective care managers have a passion for solving complex patient problems and are typically more tenured than health coaches.

Explore other care management roles

The health coach and the high-risk outpatient care manager are only two staff among many within the acute, ambulatory and post-acute enterprise.

Our Staff Audit Tool organizes emerging care management job titles by role function, provides explanations for each one, and outlines typical responsibilities and tasks.

For example, "high-risk outpatient care managers" are also often called "RN care managers" or "ambulatory case managers." No matter what the title, all staff with these roles should focus on developing care plans for their subset of high-risk patients and ensure all providers are adhering to those plans.

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  • 1The activities of the health coach may reduce unnecessary utilization, as a secondary effect of better primary care management.

    2CMS Demonstration covered top 10% of high-risk, high-cost Medicare patients; current top 5% population includes medically complex who would benefit from care management (multimorbid chronic, one severe chronic, mental health/behavioral health/substance abuse, lack of socioeconomic resources to manage illness); excludes medically complex (i.e. complicated obstetrics, trauma).