Complex Case Management
Program Overview

The Patient | The Team | The Value | Chronic Complex Case Management

The Patient

The Complex Case Management program consists of focused, high intensity support for the sickest and most costly 1 percent of a population. This subset of the patient population represents approximately one-third of claims costs. Savings are achieved through reductions in hospital utilization and related costs. Importantly, the hospital avoidance occurs through a voluntary reduction in services chosen by the patient as a result of education and the establishment of a strong support structure.

We define complex patients as those whose serious medical diagnosis is compounded by major social, psychological, or financial issues. Typical characteristics of the cases we manage include:

• Significant, often life-limiting diagnoses such as late-stage cancer or end-stage chronic diseases; multiple serious co-morbidities;
• Care involving a large array of providers whose efforts are typically not coordinated; and
• Cases where serious psychological, pain management, social, and other non-medical needs detrimental to the patient are present and, thus, have the potential to drive costs.

The full complexity of these patients' situations is often under-recognized by their providers and by the healthcare delivery system. Patients in these unfortunate circumstances often feel isolated, disempowered, pain-ridden and frightened. Without highly specialized, focused attention, they often fall into a state of debilitating disease compounded by woefully inadequate social, financial and emotional support.

The Team

Facing a serious illness can be frightening and confusing. Patients may wonder where to turn, how to learn about their treatment options and how to ensure that their beliefs and wishes are known.

As their advocate, the Complex Care Team helps patients, their families and their physician. If a patient is eligible for this program, a registered nurse called a care manager is assigned to that person. The nurse is there to help patients take control; to protect thier priorities, privacy and dignity; to provide them with information about their illnesses and healthcare options; and to help give them the freedom to take care of what is really important.

Other members of the Complex Care Team include the clinical account manager and the Alere medical director. The clinical account manager, who is also a registered nurse, works closely with the care manager to provide case direction and insight. The medical director is a practicing physician who reviews the care plan weekly with the other team members to anticipate issues and, if necessary, communicate them to the patient's physician(s) in order to help the physician(s) determine the appropriate course of action.

The Value

Improved Financial Outcomes:

• $8,000 net savings per case managed
• ROI range of 2:1 to 3:1
• Approximate net savings:
  • $12 million/million commercial lives or $1.00 PMPM
  • $7.5 million/one hundred thousand Medicare lives or $6.26 PMPM

Excellent Patient Satisfaction:

• Response rate always over 50%

Chronic Complex Case Management

Alere also offers a Chronic Complex program that targets high-risk patients whose management needs fall between our Complex Care Management services and the cases effectively addressed by disease management and health plan case management programs. What distinguishes our two programs is that Complex Care provides on-site care and the Chronic Complex program is telephonic-based.

Chronic Complex cases are more heterogeneous in terms of diagnostic mix, severity of illness and care management needs than the Complex Care Management population. These patients have advanced chronic diseases with multiple co-morbid conditions or complicated acute diseases as well as other diseases that are not a part of our usual Complex Care Management program. This telephonic-based program addresses the top tier of chronic conditions utilizing the same proven patient-centered management approach of our Complex Care Management program.