1. Develop a care model that fits the needs and assets of your population with complex needs and high costs, and aligns with your context.
  2. Prepare for care redesign by co-creating individualized care plans and learning alongside five patients.
  3. Develop your enhanced care model through iterative testing with 25 additional patients.
  4. Develop work processes to ensure consistent care delivery as the program grows from 25 to 125 patients, and beyond.

1. Develop a care model that fits the needs and assets of your population with complex needs and high costs, and aligns with your context.

Use your knowledge of your population with complex needs and high costs to develop an enhanced care model that meets the needs of your population.

Identify the staffing structures and care partnerships that will support delivery of your enhanced care model.
Tips and guidance to develop a care model that fits the needs and assets of your population:
  • Learn about care models from others who are doing this type of work. Visit sites with best practices and talk with their organizational leaders, care teams, and care users to see if their work can be adapted to your setting.
  • A care manager is an integral part of any enhanced care model that targets populations with complex needs and high costs.


“We are seeing early life trauma as a predictor of high utilization. It’s pretty crucial to understand how traumatized patients are and the impact of early life trauma. It’s probably the leading reason to be an over-utilizer and, for example, not every homeless person over-utilizes the hospital. In fact, very few do. Not every person with addiction goes to the hospital; in fact, most addicts never go to the hospital. Not every person with mental illness is in the hospital. Not every person with a severe illness goes to the hospital. Very few do.There are all these stereotypes about who your high utilizers are. The one really underlying common theme that we’ve seen are extraordinary levels of early life trauma in childhood, and often overlapping later life trauma. We’re not trained well for this. We don’t like to talk about it and we try and medicalize interventions, and the reason they are over-utilizers is because we keep medicalizing the intervention. It’s really common to hire the wrong nurses for this work. It’s really common to have the wrong doctors involved. It’s really common to have the medicalized social workers get involved and frame this as a traditional nurse-driven care coordination and we’re going to make a care plan and tell them what to do. ‘Do what we say, see your doctor, take your medicine’, and those constructs that we’ve seen don’t work. It’s a real misunderstanding of what’s causing people to go (to the hospital), how they got to this point in their lives, what we need to do to help them in the journey.” Jeffrey Brenner, MD, Executive Director, Camden Coalition of Healthcare Providers

2. Prepare for care redesign by co-creating individualized care plans and learning alongside five patients.

The key characteristic of populations with complex needs and high costs is the juxtaposition of poor health outcomes and high health care utilization. Despite participating in many health care interventions, people in these populations often continue to struggle with poor health. As a result, your care team will need to learn what to do differently and how best to meet health care needs by co-designing care delivery methods alongside individual patients.

Co-designing an effective intervention is an iterative process that will take time and numerous cycles of improvement. The 5x method of working in multiples of five patients (e.g., 5, 25, 125, 625, etc.). can enable your improvement team to learn deeply on a small scale with a lower investment and low risk of failure. Existing staff can often fit small tests of change into their current workload.

Co-create and carry out care plans with five patients from your target population to identify effective methods for engaging patients and providing services.
Test methods to effectively engage five patients from your target population at different stages of the care journey, including recruitment, engagement, and flow through the enhanced care model.
Identify what you are learning that informs your care design or redesign.
Tips for engaging five patients in your target population to inform how you might redesign your care model:
  • Help individuals in your chosen population identify life activities that bring them meaning and help them build those activities into their daily lives.
  • Identify what matters to an individual or makes them feel happy, alive, and connected to the community. Build on activities that are working well for the person, and help them reconnect to elements they would like to rekindle.
  • Consider how to provide whole person care that addresses social, physical, and behavioral health goals and actions.
  • Think broadly about what people need to achieve their goals and build a healthier life (identify touch points and services).
  • Use motivational interviewing or other suitable approaches to identify life- and health-related goals that the patient is willing and able to address.
  • Discover how life goals and health goals are connected.
  • Start with small action plans that can set up individuals for success over time and build confidence to manage their health.
  • Discover how to optimize care for people with complex needs and high health care costs by providing the right care, at the right time, with the right provider, at the right location.
  • Involve any preferred support people in care planning and/or carrying out the care plan, as determined by the patient.
  • Celebrate patient-identified successes and problem-solve quickly.

“We started with the family care clinic because it already exists to address complex primary care needs. As we started to engage clients in a different way, it became evident what we would need to do differently. For example, the health coach approach — identifying other services we needed to surround that person with — that’s where we started to engage addiction, mental health, and home care because our clients would identify who else they also are working with. Our model has been evolving out of work with a small number of patients, then a bigger number, and that’s how we start to figure out what the next step is. It’s kind of like driving in the dark when it’s foggy with the headlights on, and you can only see so far in front of you.” Jo Ann Beckie, Executive Director, Integrated Quality Management, Alberta Health Services - Calgary

Tips and guidance to prepare for care redesign:
  • The important thing at this stage is to get started and begin learning. Do not “let the perfect be the enemy of the good”! You can identify these five patients:
    • From the interviews with patients you conducted to learn more deeply about the assets and needs of the population
    • From referrals from PCPs or their care team members, staff in social service agencies, and behavioral health staff
    • From utilization reports
  • At this stage, identify one or a few staff members who are interested in learning and testing how to provide care differently and free up enough of their time from normal duties to work with the five patients.
  • Strive to do all that is needed to give these five patients “perfect care.” In this process, you will learn a lot about navigating through the system, engaging difficult-to-engage individuals, and the barriers your patients face.
  • Try really different things. If you only have office-based care, test doing home visits; if you only do phone care, test meeting the patient at the office visit or while they are in the hospital; if you always put the medical agenda first, test just listening first. The goal here is to learn what you have to do differently to get much better outcomes.
  • Begin to understand what may or may not be sustainable at a larger scale.
  • Explore bringing high-intensity, high-resource interventions to individuals who have very high health care costs and determine if there is a good return on investment for some individuals. For example, for an individual who frequents the emergency department at an extremely high rate, having a daily interaction may well help the individual stabilize their situation and be worth the staff costs.


“Don’t do what you’ve done before because it probably hasn’t worked if you still have a segment of people that are very high cost. Start with the notion that you need to do something different than you’ve done before. Be very open to that. Break out of the mold of traditional case management models or medical models and think really broadly about all the different ways we refer to patients — who are individuals and people, residents of our communities — and all the different touchpoints and services they may need to help them build a healthier life for themselves. Often that means thinking about partnerships with community-based organizations or social service agencies that are not always thought about as part of the health care system.” Rebecca Ramsay, BSN, MPH, Executive Director, Population Health Partnerships, CareOregon

3. Develop your enhanced care model through iterative testing with 25 additional patients.

As you move from working with five patients to 25, it is likely that your original care model design will remain consistent, but the iterative cycle of scaling up to serve a larger number of people will help you refine what needs to be included in your care model and how to deliver the care.

Based on your experience with five patients, identify useful interventions and develop a plan to test those interventions with 25 patients.
Begin to establish reliable work processes and systems.
Develop systems to ensure staff have the necessary expectations, training, and skills to productively engage with patients with complex needs.
Develop process measures to track performance of key tasks.
Tips and guidance to develop your enhanced care model through iterative testing:
  • Review how Stanford Coordinated Care  and CareOregon developed and supported their staff to effectively carry out the enhanced care model.
  • Provide regular opportunities for team members to learn from each other. Highlight specific skills of staff in meetings and invite team members to share their care processes.
  • Design a team-based approach to overcome existing health care silos.
  • Anticipate that non-licensed health workers will need support from others on the care team and will need training to maximize their contribution to the patient and care team.
  • Build mentor, peer, or guide roles into the care team to support and deeply engage patients.
  • Ensure that staff are working at the top of their skill-set. For example, some enhanced care programs train medical assistants to be “care support” providers and others develop community health worker and patient navigator roles.
  • Recruit staff from organizations where candidates are likely to be aligned with your organization’s values and mission.
  • Re-train staff to take on different roles in the enhanced care model. For instance, some programs give more responsibility to staff who embrace the vision and workflow of the enhanced care model, while less engaged staff are transitioned to traditional programs and roles.
  • Invest in the time and resources needed for your care team members to form relationships with patients.


“It’s so important to identify the right people to do the work. Who you hire into the position of care manager is really important and training them well is also important. We have nurses and social workers in our organization. We put social workers in the mix for two reasons. One is we have a population with pretty high behavioral health needs and so we want people who are comfortable working with these individuals. And two, we find that social workers are very effective for the approach of starting where the patient is.  This is a core social work concept, which we believe is central to engaging a patient and making an impact.

Really listening to patients and understanding what’s important to them, that’s our starting point.  Patients have to be able to say, “This is what I want to do. I’m willing to work with you in this regard, because this is an outcome that I can relate to.” I think that having members from different disciplines who can work well together and trust each other is essential.  Selecting the right mix of staff for your population is key. It’s tailoring the type of individual employee you want as your care manager to the population you intend to serve.”Eleni Carr, MBA, LICSW, Senior Director of Care Integration, Cambridge Health Alliance

4. Develop work processes to ensure consistent care delivery as the program grows from 25 to 125 patients, and beyond.

As you move from working with 25 to 125 patients and beyond, your improvement team should standardize care processes, communication processes, and data reporting processes. This work will help your improvement team develop reliable and efficient methods for delivering appropriate care, and help your patients and care team consistently achieve their intended results.

Standardize your care processes to ensure reliable care delivery, including recruitment, assessment, engagement, and step-down to usual care.
Standardize your communication and data reporting systems to create ongoing opportunities to improve the care model.
Tips and guidance to develop work processes:
  • Weekly meetings can support staff in building self-reliance, including always having an active goal the team is working toward with each client, and encouraging forward progress and movement through the program.
  • Continuous communication at every level is important. It should be positive, while accepting the challenges that exist.
  • Keep an open mind and open lines of communication.
  • Create a multi-faceted ongoing learning process.
  • Clearly document processes and make work “easy to do.”
  • Recognize that many victims of trauma also work in the health delivery system, and programs should incorporate purposeful debriefing sessions and support to try to avoid re-traumatization.
  • Learn your way to the right caseload or panel size, and don’t overpromise. Care teams often overestimate the number of patients that they can effectively serve. Caseload sizes will differ depending on the characteristics of your program. For example, some organizations provide a “light-touch” approach with the goal to transitioning patients quickly to other services. In contrast, other enhanced care models work much more deeply with a patient.

“Case managers spend a lot of time exploring where to go when they face issues. This includes documenting what services are available and building on existing knowledge rather than recreating the wheel every time. In order to do this, case managers have a standing item in their bi-weekly meetings where clinicians discuss what was successful that they did and how they did it. This provides information for other case managers to follow.”Jo Ann Beckie, Executive Director, Integrated Quality Management, Alberta Health Services - Calgary