Colorado

Denver Health Medical Plan's Targeted Case Management (TCM) program provides intensive, personalized support, monitoring, outreach and engagement for individuals with medical and/or behavioral care needs and who are also high cost/high utilizers of the healthcare system. TCM uses cost and utilization data to identify high-risk patients by number of emergency room visits, number of unplanned emergency room to hospital admissions and number of high-cost admissions.  Services include: a comprehensive needs assessment and periodic reassessment, care coordination, resource connection, patient education, motivational interviewing to assess and support behavior change, collaboration with community organizations and health systems using a team-based approach to address complex, multi-factorial needs and co-management with community case managers. 

Partner Organizations

• Denver Health
• Community organizations

Target Population

Adults who are high-cost and/or high ED utilizers

Care Team

Physicians, nurses, social workers, care coordinators, case managers

Timeframe

2012 - present

Results/ Studies

N/A

Funding

Health plan

Resources

Program website