Improving Care for High-Need, High-Cost Patients: The View from a Community Health Worker and a Social Worker

Many health care organizations have been experimenting with programs to better serve Medicaid beneficiaries with complex health and social needs. In 2015, CareMore Health developed a program in Memphis, Tennessee to provide comprehensive care to this group of patients. Early analysis revealed that the top five percent of CareMore’s highest-cost Medicaid members in Memphis incurred roughly 70 percent of all spending. Most of the people in this group had multiple chronic medical conditions, often with co-occurring behavioral health conditions and significant social needs, ranging from housing instability to food insecurity.

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