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The Common Attributes of Successful Care Manager Programs for High-Need, High-Cost Persons

A Cross-Case Analysis

Thurber, Emilia G. MPH; Boyd, Cynthia MD; Leff, Bruce MD; Wolff, Jennifer PhD; Anderson, Gerard PhD

The Journal of Ambulatory Care Management: October/December 2019 - Volume 42 - Issue 4 - p 230–241
doi: 10.1097/JAC.0000000000000305
Original Articles

Many programs use care managers to improve care coordination for high-need, high-cost patient populations. However, little is known about how programs integrate care managers into care delivery or the attributes shared by successful programs. We used a case study approach to examine the common attributes of 10 programs for high-need, high-cost individuals utilizing a longitudinal care manager that had achieved success in reducing cost, improving quality, or increasing patient satisfaction. Through interviews with program leaders and document review, we identified 10 common attributes of successful care manager programs, offering insights for providers aiming to better serve the high-need, high-cost population.

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (Ms Thurber and Drs Boyd and Leff); and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Drs Wolff and Anderson).

Correspondence: Gerard Anderson, PhD, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 302, Baltimore, MD 21205 (

This study was funded by the Commonwealth Fund and the Dean's Summer Research Funding from the Johns Hopkins School of Medicine Office of Student Affairs. The sponsors were not involved in the study concept or design, recruitment of subjects or acquisition of data, data analysis or interpretation, or preparation of this manuscript. The authors thank the following interviewees for their time and support of their research: Alena Baquet-Simpson, MD, of Medicare at Aetna; Jonathan K. Weedman, CCTP, LPC; Jane Duck, RN, of CareOregon; Diane Littlewood, RN, BSN, CDE; Jackie McCole, RN, CCM, of Geisinger Health Plan; Kenneth Coburn, MD, DrPH, FACP; Sherry Marcantonio, MSW, of Health Quality Partners; Julie Bluhm, LICSW, of Hennepin Health; JoAnn Milicia, RN, BSN, CCM; Kathleen M. Mylotte, MD, of Independent Health; Joanne M. Kaufman, RN, MPA, of Massachusetts General Hospital; Steve Tierney, MD, of Southcentral Foundation; and John Lynch, MD, of the Washington University School of Medicine.

One of the authors, Dr Cynthia Boyd, receives a royalty ($600 per year) for an UptoDate article on multimorbidity. Dr. Boyd's time was partially supported by NIA K24 AG056578.

The other authors do not have any financial disclosures or conflicts of interest.

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