A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population

Health care systems have made concerted efforts to improve value for individuals with complex and chronic disease. Despite these efforts, this population (and the Medicaid population in particular) has been historically difficult to impact as many members are disproportionately impacted by social determinants of health that interfere with their ability to engage the health care system effectively. Transactional, solutions-based interventions to resolve barriers to care have been ineffective at either improving outcomes or reducing cost in the long term. The authors identify 3 core barriers that prevent time-limited, transactional interventions from effectively solving complex health and social problems: trust, self-efficacy, and complexity. By evolving from a transactional framework to a relational framework, case managers can develop relationships with clients that will help overcome these barriers. More specifically, clinical case management can be utilized to resolve these barriers by implementing a long-term, relational approach with clients through 5 key principles: ensuring continuity of care, leveraging the case management relationship, titrating support and structure, engaging flexibility, and facilitating patient resourcefulness. This article discusses how these principles resolve the identified barriers and how such a model is currently being executed in University Hospital's system. RWJF Grant I.D Number is 98426.