High-risk patients present a unique challenge to the health care system. These patients often need a focused approach to effect self-management and adherence. At Massachusetts General Hospital, the Case Management Alliance Program was initiated in 2007. It is a practice-based program where case managers and primary care physicians collaborate to develop an individualized and comprehensive Health Care Maintenance plan. 

Our program currently provides high-risk case management in three of our primary care practices. It targets patients insured by our top three commercial payers. Thus, while they have a commercial insurance benefit, they have other barriers to care about that significantly impact their overall health management. Most patients do not qualify for community resources available to the older individual. This population has varying ages and needs including, but not limited to: chronic disease education, transportation, and financial aid.

The program enables our health care teams to identify and target high-risk patients, assist them in navigating the health care system while maximizing their commercial benefit, and move toward increased levels of self-care. In addition, our case managers have succeeded in becoming integral members of the practice, and have complemented the work of the Primary Care Physicians.