Chronic Condition Care Management

From Managing Vulnerable Populations

This is an excerpt from our research briefing, Managing Vulnerable Populations.

This briefing explores strategies for improving care management for three distinct Medicaid patient populations: pregnant women, patients with chronic conditions, and dual-eligible patients, or those who qualify for both Medicare and Medicaid.

Partner to Develop Comprehensive Resources

Care resources need to be ubiquitous, starting with inpatient case managers and branching out to the community. For chronic conditions, make sure care managers are directing patients to the right site of care. Collaborate with other providers to scale solutions across the patient population, and use resources in the community to extend the reach of the care team.

While maternity care has the greatest number of admissions, most of the opportunity to improve Medicaid outcomes requires moving beyond discrete episodes and into ongoing care management that uses the whole "medical perimeter"—including disease management programs, post-acute care partnerships, and medical home infrastructure.

  • For example, one organization had a patient that was filling blood pressure medication in the ED.

    Every 30 days, the patient would return to the ED—unable to get into a primary care clinic after hours. Solving this one patient’s problem stopped 12 visits to the ED per year.
  • 35%

    General practitioners not accepting any new Medicaid patients
  • 40%

    Internists not accepting any new Medicaid patients

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