Multimorbidity Care Management


A large-scale intervention study evaluating an innovative primary care physician-nurse team-based care management program for patients with multimorbidities. This study includes predictive modeling-based patient selection, and has shown favorable preliminary results.

Context and Aims

Patients with multiple chronic conditions require proactive, coordinated care management to effectively manage numerous health conditions comprehensively and not each as a discrete problem.

Studies show that providing primary care based care management by a nurse-physician team targeted to complex multimorbid patients, can improve their overall quality of care and outcomes, such as the Guided Care model of care developed health care professionals at Johns Hopkins University.

Based on this evidence and model of care, Clalit, in collaboration with researchers from the University of Haifa and the Gertner Institute, created the Comprehensive Care for Multimorbid Adults Project (CC-MAP). The CC-MAP aims to improve the quality of care and reduce preventable hospital admissions for adult Clalit members with multimorbidity who are at-risk for deteriorating in their health status and incurring high future costs.

Research Approach

The CC-MAP was launched in 2012, among selected primary care clinics, in which intensive training was provided to the nurse-physician care teams that would participate in the project. The project preparation also included the development of a summary of integrated clinical guidelines, highlighting care recommendations for 10 of the highest impact and most prevalence chronic conditions.

Tailored predictive algorithm: As part of the CC-MAP, a patient selection process was developed that balances the needs to systematically identify patients who are at-risk for future high costs (according to the Adjusted Clinical Groups [ACG]® case mix system’s predictive algorithm) and to distinguish who can benefit from proactive care management.


Intervention Program: Each CC-MAP nurse follows up to 100 of the highest-risk multimorbid patients of 3-4 primary care physicians in her clinic.

Components of the intervention include:

  1. Identification of high-risk patients
  2. Comprehensive assessment of the patient’s and family’s needs
  3. Generation of a coordinated care plan based on integrated care guides
  4. “Multimorbid Action Plan” for patients
  5. Patient-centered care and caregiver support including self-management education
  6. Proactive monitoring according to the plan
  7. Coordination of care from all providers including follow-up to institutional transitions

CC-MAP components image

A comparative cluster design was employed with an intervention group and two control groups (an “active control” group and a “covert” control group, not actively enrolled in the study). Patients in the control groups receive usual care in their primary care clinics, and the “active control” group completes study questionnaires at baseline, 12 and 24 months after enrollment.

 Key Findings and/or Potential Impact

The study is still ongoing; yet, early results indicate favorable findings for the quality of chronic care, in decreasing the number of days in hospital, and for patient reported outcomes in the intervention versus the “active control” group. After 3 years of operation, the CC-MAP care management model for multimorbid patients has been feasibly implemented in the Israel healthcare context, with future plans to gradually extend the program to similar clinics and populations throughout Clalit.




Cohen CJ, Flaks-Manov N, Low M, Balicer RD, Shadmi E. High-risk case identification for use in comprehensive complex care management. Population Health Management, 2015. 18(1): p. 15-22.

Boyd CM, Boult C, Shadmi E., Leff B, Brager R, Dunbar L, Wolff JL. Guided care for multimorbid older adults. The Gerontologist, 2007. 47(5): p. 697-704.

Balicer R, Shadmi E, Geffen K, Cohen AD, Abrams C, Kinder-Siemens K, & Regev-Rosenberg S. Towards a more equitable distribution of resources and assessment of quality of care: validation of a comorbidity based case-mix system. Harefuah, 2010. 149(10): p. 665-669.

Balicer RD, Bitterman H, Shadmi E. Multiple chronic conditions and morbidity burden: challenges and consideration for an organizational strategy. Harefuah, 2012. 151(7): p. 388-392. [in Hebrew]