Complex Care Management involves using advanced analytics and digital tools to identify and proactively manage high-risk, high-cost patients through coordinated, personalized interventions. Digital solutions in this space integrate predictive analytics, care coordination tools, and patient engagement platforms to enable healthcare organizations to deliver targeted interventions that improve outcomes while reducing costs.
Complex care management framework
| High-risk population identification | |
Predictive risk stratification | Platforms that apply algorithms to identify high-risk patients to determine which individuals are most likely to benefit from specific interventions, and recommend targeted actions with patient-specific guidance for care teams. Example companies: Lightbeam Health Solutions, ClosedLoop, n1 Health, Innovaccer |
Rising risk tracking and utilization monitoring | Systems that track emergency department visits, hospitalizations, and care transitions across healthcare settings to enable immediate intervention, manage critical transition points, and identify patients with rising utilization patterns before they become high-risk. Example companies: PointClickCare, Bamboo Health |
| Comprehensive care orchestration | |
Cross-continuum care planning and coordination | Solutions that enable diverse care team members to collaboratively develop personalized care plans and coordinate implementation across disparate care settings and organizations. Example companies: WellSky, Dina, Olio Health |
Social care integration | Platforms that connect clinical teams with community-based organizations to address social determinants of health. Example companies: Unite Us, findhelp |
| Intensive outreach and engagement | |
Personalized behavioral engagement | Platforms supporting outreach through multiple channels (text, voice, video) while leveraging behavioral science principles to motivate engagement from hard-to-reach, high-risk patients. Example companies: Personify Health, Lirio, Wellth |
Digitally-enabled wrap-around care | Solutions that power both digital and physical delivery models to extend care beyond traditional settings, into patients’ homes and community environments, enabling care teams to provide services where patients live and interact. Example companies: Homeward Health, MedArrive, DispatchHealth, Luna, Reimagine Care |
The case for digital in complex care management
The success of complex care management hinges on three fundamental capabilities: identifying the right high-risk patients to focus on, orchestrating care across multiple providers and settings, and maintaining consistent engagement with hard-to-reach populations. While healthcare organizations recognize these imperatives, they struggle to execute them effectively using traditional approaches that are often prohibitively labor-intensive and cost-inefficient at scale. Digital solutions offer the potential to transform complex care management by precisely identifying impactable patients, enabling seamless care coordination, and fostering lasting engagement through innovative outreach strategies – all while making efficient use of limited clinical resources.
Identify high-impact opportunities with precision
Coordinate complex care across multiple settings
Drive consistent engagement with hard-to-reach populations
Health systems struggle to maintain meaningful connections with complex patients, with traditional outreach methods failing to reach many high-risk individuals who often lack access to meaningful solutions and care. A leading children’s hospital found that 50% of families in their network were not reachable by phone and one-third of all automated, outbound phone messages resulted in additional questions (AVIA Insights). Digital engagement platforms enable consistent, personalized outreach across multiple channels. Additionally, beyond just expanding reach, these sophisticated platforms leverage behavioral science principles, personalization algorithms, and precision engagement timing to significantly increase patient activation. Organizations implementing these omnichannel digital engagement strategies can achieve significant improvements in patient outreach effectiveness by substantially reducing no-show rates and improving patient care plan adherence through behavioral science-informed communication approaches. These platforms generate insights about individual communication preferences and response patterns, enabling increasingly refined approaches that drive meaningful behavior change even among traditionally disengaged populations.
Sources
- https://pmc.ncbi.nlm.nih.gov/articles/PMC10278007/
- https://guidewaycare.com/what-are-social-determinants-of-health/#:~:text=In%20fact%2C%20Aligning%20for%20Health,accounts%20for%2010%20to%2020%25.
- https://www.rand.org/content/dam/rand/pubs/research_reports/RR1200/RR1234/RAND_RR1234.pdf
- https://ecaremd.medarch.co/blog/5-ways-care-coordination-software-improves-patient-outcomes/
