Collaborative Care Models for Managing Complex Patients

Core Mechanisms of Collaboration

Interprofessional team-based care directly reduces patient load burden and improves outcomes for complex patients by distributing care responsibilities across multiple clinicians working at the top of their respective licenses, while simultaneously improving access, reducing hospitalizations, and enhancing practice efficiency, as recommended by the American College of Physicians 1, 2
Team-based care models redistribute clinical workload by enabling each team member to practice at their full scope of training and competency, with the American College of Physicians emphasizing the importance of flexible team organization based on patient needs and available clinician expertise 3, 4
Advanced practice registered nurses can independently manage stable chronic conditions and routine visits, freeing physicians to focus on diagnostically complex or acutely ill patients, with a strength of evidence supporting this approach 5

Multidisciplinary interventions and case management models have demonstrated reduced all-cause mortality and hospital admissions in complex patient populations, with the American College of Cardiology citing a study showing reduced heart failure admissions and mortality in patients with chronic cardiovascular conditions 6
Case management with telephone follow-up and home visits reduces heart failure admissions and mortality in patients with chronic cardiovascular conditions, with a moderate strength of evidence supporting this approach 6
Patient- and family-centered collaborative strategies reduce healthcare resource utilization, referrals, diagnostic tests, and overall costs while improving clinical outcomes, with the American College of Physicians recommending this approach 7

Including patients and families as active team members improves both efficiency and outcomes by reducing errors, improving adherence, and aligning care with patient goals, with the American College of Physicians citing a study showing improved medication management and reduced adverse events 1, 2
Patients who actively participate in care are more likely to report medication problems and less likely to experience adverse events, reducing downstream complications that increase workload, with a high strength of evidence supporting this approach 7
Collaborative goal setting increases self-care behaviors and reduces distress in patients with chronic conditions, decreasing urgent visits and hospitalizations, with the American College of Cardiology recommending this approach 6

Reimbursement models that incentivize team-based care are essential for sustainable implementation, with the American College of Physicians recommending risk-adjusted per-patient-per-month care coordination fees and bundled payments 4
Risk-adjusted per-patient-per-month care coordination fees support the infrastructure needed for team-based care, with a moderate strength of evidence supporting this approach 4
Bundled payments and accountable care organization models create incentives for all team members to work together in highly coordinated ways, with the American College of Physicians recommending this approach 4

Multidisciplinary interventions bridging hospital admission and discharge to home or transitional care have demonstrated effectiveness for managing complex patients, with the American College of Cardiology citing a study showing reduced readmissions and improved outcomes 6
Case management with telephone follow-up and home visitations after discharge reduces readmissions and improves outcomes, with a high strength of evidence supporting this approach 6
Specialty clinic follow-up with seamless information sharing back to primary care improves outcomes and reduces fragmentation, with the American College of Physicians recommending this approach 4