High-risk patients have diverse and often overwhelming needs, and they’ll need more help than primary care can offer.
The most important relationship a high-risk patient should have is with a dedicated care manager, not a primary care physician, because care managers can coordinate these diverse needs.
At Massachusetts General Hospital, the care manager is part of a multidisciplinary team focused on managing the top 5% of highest-risk Medicare patients. With over 20 years of experience, the nurse proved to be a critical member of the team, serving as the main point of contact for patients.
From clinical to non-clinical care, care managers make sure the patient has access to the extra support they need, for everything from behavioral health care to transportation and housing. The goal is to coordinate, not duplicate, existing health system resources to improve care quality and reduce unnecessary utilization.