Though every healthcare leader likely has a care management or case management resource today, our current resources were not designed for managing populations under risk-based contracts. In fact, they were mostly created under a fee-for-service system and, as a result, addressed only specific needs of an individual care silo. Often missed is the totality of a given patient’s complex clinical and non-clinical care needs.

What to Consider When Building a Care Management Model

If you are embarking on or laboring midway through redesigning your enterprise program, it’s best to accept this truth up front: care management redesign is not a silver bullet for solving every patient’s problem. Even if that initiative was achievable, execution is impossible because the result would be an overextended, inefficient resource. Secondly, a smaller number of patients will always consume a disproportionate amount of shared resources.

With that in mind, let’s envision building a care management model from scratch. We’ve established an agreed-upon core set of ideal features for this very purpose:

  1. We want to ensure care plans are personalized for each patient.
  2. We want the flexibility to identify complex patients with complex needs (i.e. the social determinants of health).
  3. We want to orient the care plan toward goals meaningful to both the patient and their family.
  4. From a population health management standpoint, we want to see clinical costs and measured benchmarks tracked, from driving longitudinal improvement through a unified care plan.

To achieve our goals, we must move the patient to the most appropriate ambulatory access point. Then we need to accommodate these patients and their needs whenever applicable.

How do we meet our redesign ambition for care management? The first step is targeting populations prioritized by risk factors.

Patient Segmentation

Provider organizations must first determine which patients to focus on for ongoing management. They do this based on risk stratification of a population that uses a mix of clinical and claims data.

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This pyramid, which might be familiar, is a way for organizations to take various sets of data and segment populations appropriately. Administrators of effective care management programs do a good job identifying their high-cost, rising-risk, moderate-risk and healthy patients. They know effective care management is not about managing one population—it is about managing three populations at a minimum and, often, even more.

The following questions are a wonderful start for segmenting populations by risk factors in order to allocate appropriate staffing:

  • Who are the high-cost and rising-risk patients whose needs we must anticipate today?
  • Who are the patients with both multiple conditions and multiple risk factors?
  • Which patients are moving into rising-risk and moderate-risk populations?
  • Which populations demonstrate gaps in care—patients for whom we are doing everything possible to ensure their needs are met in order to prevent cycling into the rising-risk or high-cost population categories?

But that’s only the beginning. What many burgeoning care management programs leaders fail to do after this initial step is define criteria for the segmented patient populations they manage.

Defining Criteria for Segmented Patients

Inclusion criteria for managed patients must be established at the start of any care management program. Otherwise, if those target patients aren’t openly disclosed, how can care managers advise physicians and other care team members as to the ideal care management program for certain populations?

Surprisingly, many seasoned healthcare professionals have never defined inclusion criteria for target patients in segmented populations. Communicating which patients care managers must target for longitudinal management is equally as important as knowing which patients are not. Provider organizations have more than enough patients to manage. In the beginning of your program’s launch, prioritize patients who express readiness to change, no matter how small in number, so that you increase the likelihood of meaningful improvements in quality of health and life.

Care managers often prioritize and deprioritize a list of target patients every day, including individuals deemed not at risk of inflating resource utilization and costs. To do that, care managers need to deprioritize patients who meet exclusion criteria; moreover, patients declining prioritization or support are included in this category as well.

Prioritization Questions to Discuss

Lastly, here are key discussion questions to ensure effective prioritization of target populations to help launch your redesign efforts.


  1. Which patient populations do we want to prioritize for ambulatory care management given our current level of staffing?
  2. What should be the targeted caseloads for each care manager so we can determine if and when more FTEs are required on a care team?
  3. Do we need to hire more FTEs to support ambulatory care management?
  4. Should we formalize care coordinators as complex care managers deployed to manage highest-risk patients?
  5. How do we differentiate the responsibilities of RNs and social workers on the care team?
  6. What inclusion and exclusion criteria will we use to determine if a patient is appropriate for active care management?

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