Association of a Chronic Care Management Model with Health Care Costs and Utilization
In brief
Care management linked to $3,008 lower acute-care costs in high-risk patients
In a matched analysis of high-risk patients, engaging in a multidisciplinary chronic care program was associated with fewer hospitalizations and emergency visits and $3,008 lower acute-care expenditures. Readmissions did not change. Because this was an observational study, the results show an association, not proof that the program caused the reductions; whether they apply beyond these Maryland practices remains unclear.
- Journal
- Journal of general internal medicine (Q1)
- Published
- 21 October 2026
- Study design
- Case-control study
- Evidence level
- Level 3, Low (CEBM 3b)
- Authors
- Anjali Bhatla, Alexandra K Mueller, Jason Fu, Teodoro Norman, Jonathan Eldridge, Megan M Tschudy, et al.
- PMID
- 42907693
- DOI
- 10.1007/s11606-026-10948-9
Why clinicians should know about it
- Picked for Internal Medicine (paper of the day, 23 October 2026): Multidisciplinary chronic care associated with fewer acute visits
Abstract
BACKGROUND: Chronic Care Management (CCM) programs aim to reduce avoidable acute care utilization through improved care coordination, but evidence regarding their effectiveness among high-risk patients remains mixed. OBJECTIVE: To evaluate the association of a comprehensive CCM program delivered through a Care Transformation Organization (CTO) with acute care utilization and acute care expenditures. DESIGN: Observational pre-post study with a concurrent comparison group and propensity-score-matched analysis. PARTICIPANTS: High-risk patients attributed to Maryland Primary Care Program (MDPCP) primary care practices supported by the Johns Hopkins CTO between December 2021 and January 2024 who engaged in CCM (n = 1219) or were randomly sampled from non-engaged patients (n = 2438). INTERVENTIONS: Multidisciplinary CCM delivered through the Johns Hopkins CTO, with registered nurse care managers supported by pharmacy, behavioral health, and community health worker services as clinically indicated. MAIN MEASURES: Acute hospitalizations, emergency department (ED) visits, 30-day readmissions, and associated acute care expenditures during the 6 months before and after the index date. KEY RESULTS: Among 3657 patients, CCM participants had substantially higher baseline acute care utilization than non-engaged patients. In unmatched analyses, CCM was associated with relative reductions in hospitalizations (54%; incidence rate ratio [IRR], 0.46; 95% CI, 0.35-0.62) and ED visits (33%; IRR, 0.67; 95% CI, 0.52-0.85) compared with controls, without a significant difference in readmissions. In the propensity-score-matched cohort (n = 2370), CCM was associated with greater reductions in hospitalizations (average treatment effect on the treated [ATT], - 0.22; 95% CI, - 0.29 to - 0.16) and ED visits (ATT, - 0.20; 95% CI, - 0.28 to - 0.13), but not readmissions (ATT, 0.00; 95% CI, - 0.03 to 0.03). Acute care expenditures were $3008 lower among CCM participants in the matched analysis. CONCLUSIONS: Among high-risk patients attributed to MDPCP practices supported by the Johns Hopkins CTO, CCM engagement was associated with reductions in hospital and ED utilization and associated acute care expenditures.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.