Older patients with multiple chronic conditions are major users of health care, as they often see multiple specialists, frequently visit the emergency department (ED), and have multiple hospital admissions per year. One model to improve care for these high-risk patients is case management, with a nurse or social worker (SW) taking responsibility for coordinating and implementing a patient’s care plan. Case managers are now frequently used at health systems participating in the Medicare Accountable Care Organization (ACO) program. However, case management is resource- and time-intensive; programs vary widely, with mixed effectiveness, and there is little guidance for health systems to identify patients who would benefit the most.
