Care Transformation Center Blog

What's the right ratio of care managers to patients?

by Carrie Kozlowski

Care managers are an integral part of the primary care team, particularly in navigating and activating high-risk patients across the care continuum. In fact, 80% of population health managers plan to increase the number of care managers in the next three years.

But care managers with clinical qualifications can command high salaries—about $90,000 on average. Organizations hoping to expand care managers' purview to also prevent rising-risk patients from escalating cannot maintain the low 50:1 to 100:1 care manager-to-patient ratios that are standard for high-risk care management programs.

So what's the right ratio to manage care for an entire population? Here's the approach we use with Crimson Care Management members.

Three questions you need to answer to find your ratio

I start every ratio recommendation with the following baseline ratios, which assume a typical risk stratification: 3-5% of the population deemed high risk, 15-20% rising risk, and the remainder at low risk:

  • Commercial population to care manager: 5,000:1
  • Medicare population to care manager: 3,000:1
  • Medicaid population to care manager: 1,500:1

But to customize the ratio based on an organization's population health goals and infrastructure, we have to answer three questions.

What population type is under management?

We start by looking closely at the patients, including the risk within a population, payer type and specialty program enrollment, ER and IP visit frequency, discharge disposition rates, readmission rates, and physician appointment attendance. We want to understand the patients’ intrinsic need and the organization’s current ability to serve them efficiently, such as the reach of its primary care network and post-acute care partnerships.

Which care models will be in place?

Most of our partner organizations reorganize their care management infrastructure as they add care management capacity. Care manager ratios should adjust to fit the desired patient flow into—and out of—active care management. Considerations include:

  • How will care management functions align to organizational structures like physician practices or facility locations?
  • How will patients qualify for care management contact?
  • What care plans or care goals will guide care manager workflow?
  • When will falling-risk patients “graduate” from active care management?
  • What functions will be centralized?

By overlaying the population characteristics with the structural requirements set by care management models (e.g, serving a specific number of physician practices), we can start to anticipate the total care management capacity required.

Who will manage care?

The most successful population health managers define "care manager" broadly, flex roles to match population needs, and have an RN/NP-led team supported by centralized staff within the organization and community partners.

To create a complete care manager roster, answer these questions:

  • Who are your current care managers? What skills or qualifications do they have? What is their tenure? Do you anticipate attrition? Will you redeploy them in an updated care model?
  • For new care managers, do they have care management experience? What is your onboarding/training process and what is the ramp-up period for them?
  • Will you offer centralized resources to support care managers (e.g., a social worker, pharmacist, or authorization specialist supporting several care management teams as needed)?
  • Is any care management workflow currently performed by other parts of your organization (e.g., a readmissions prevention program or a disease management program)? Will your care managers now perform those steps or coordinate the work of others?
  • Have you provided a way for care managers to assign tasks and track task completion by other employees or community partners/providers, or will the process be entirely manual?

Download care management and population health job descriptions

Expanding care management isn't optional

We've seen a spectrum of ratios among our members, from a 10,000:1 relationship for managing low-risk patients with the help of a wellness partner, to a 100:1 relationship for coordinating community nursing programs and behavioral health care for pregnant Medicaid patients.

But all our members have scaled up their care management capacity and extended scarce resources across the largest number of patients in need. Ratios, at best, serve as directional guidance for what is possible in population health—better outcomes and lower costs for more patients.

Use your care management resources efficiently

Learn how to scale primary care staff resources, use virtual channels to manage populations over time, and engage patients beyond the clinic.

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