This two-arm randomized controlled trial evaluated the impact of a Stepped-Care
intervention (predictive analytics combined with tailored interventions) on the healthcare …

Complex care management (CCM) or hot spotting programs identify and manage high-
need/high-cost patients, improving long-term health quality and medical costs. Typically …

Importance Despite longstanding efforts to improve health care quality for patients with
complex needs who are at highest risk for hospitalization or death, to our knowledge, no …

Background Healthcare utilization is skewed to a subset of high-need, high-use patients, but
optimal models of care are not known. Purpose To reduce emergency room (ER) use and …

Methods: This mixed method embedded, explanatory case study design included surveys of
general practice staff and focus groups with patients, carers and coordination centre staff …

The publicationof Atul Gawande's groundbreakingNew Yorker article,“The Hot Spotters,” 1
intensified interest in identifying “high-users,” those patients who use the most health care …

Background Population health management tools (PHMTs) embedded within electronic
health records (EHR) could improve management of high-risk patients and reduce costs …

Background: The Veterans Affairs (VA)-developed Care Assessment Need (CAN) score, a
risk-stratification tool used to identify complex high-risk patients and guide VA care …

Intensive management programs may improve health care experiences among high-risk
and complex patients. We assessed patient experience among (1) prior enrollees (n= 59) of …

Developing and implementing an intensive interdisciplinary medical home within a large
academic medical center was feasible. 2. Deploying a complex care management program …