Addressing the Social and Medical Needs of Complex Patients

Resources

Complex patients have multiple chronic conditions and often struggle to manage them. They may have a number of functional limitations, or a combination of vulnerabilities that are exacerbated by social disadvantages such as homelessness, low income, behavioral health issues, or being a racial and ethnic minority.  

Because this is a very high cost population that often experiences unmet social needs and care coordination failures, there is tremendous opportunity to improve the lives of these patients and possibly reduce net social and health spending. Models of care that are data driven, tailored to patient needs and integrate care from healthcare and social service providers are extremely promising and deserve the sustained attention of policymakers and advocates.  

National Resources

The Hub's Inventory of Local Programs Targeting Complex Patients - This inventory contains profiles of nearly a hundred programs across 36 states and territories. To qualify for inclusion, programs must specifically target complex patients and go beyond medical care coordination to offer either a level of social services integration or a program that specifically addresses socioeconomic disparities. Programs or models operating in multiple states are listed under "Multistate."

National Center for Complex Health and Social Needs - Launched in 2016, this center aims to improve outcomes for patients with complex medical, psychological, and social needs. It works to coalesce a new field of healthcare by bringing together a broad range of clinicians, researchers, policymakers, and consumers who are developing, testing, and scaling new models of team-based, integrated care.

The Play Book - Five foundations partnered with the Institute for Healthcare Improvement to create a dynamic website that highlights the challenges facing adults with complex health and social needs and provides direction on how to meet those needs through a variety of resources that detail care models, policies and more.

Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value  and Health - This National Academy of Medicine publications summarizes insights and perspectives on how to better manage the care of the high-need patient population from three workshops held between July 2015 and October 2016.

Identifying the Complex Patient

• Caring for High-Need, High-Cost Patients—An Urgent Priority, New England Journal of Medicine (September 2016). 

• Health System Performance for the High-Need Patient:  A Look at Access to Care and Patient Care Experiences, The Commonwealth Fund (August 2016). This study compared the experiences of adults with high needs—those with three or more chronic diseases and a functional limitation—to all adults and to those with multiple chronic disease but no functional limitation.  

• How High- Need Patients Experience Health Care in the United States, The Commonwealth Fund (December 2016). This study investigated the challenges faced by complex patients and their experiences with the health system and potential opportunities for improvement.  

Successful Models of Care

• Better Care Playbook - Reference guide to promising care models.

• Hennepin Health:  A Safety Net Accountable Care Organization For The Expanded Medicaid Population, Health Affairs (November 2014). This study provides and overview of Hennepin Health—a county based safety-net accountable care organization in Minnesota.  

• Project ECHO Complex Care Initiative:  Building Capacity to Help “Superutilizers” in Underserved Communities, The Commonwealth Fund (August 2016). This study investigated Project ECHO, a program in New Mexico addressing complex patients using videoconferencing sessions led by experts in the medical field.  

• Opportunities to Improve Models of Care for People with Complex Needs, Center for Health Care Strategies, Inc. (November 2015). Explores promising approaches ranging from pilot projects to statewide efforts, and identifies opportunities for improvement.  

• Camden Coalition and Healthcare Hotspotting. The Camden Coalition is a citywide coalition of hospitals, primary care providers, and community representatives that collaborate to deliver better healthcare to our most vulnerable citizens. Hotspotting uses data to discover the outliers, understand the problem, dedicate resources, and design effective interventions. It is a movement for a new system of multidisciplinary, coordinated care that treats the whole patient and attends to the non-medical needs that affect health: housing, mental health, substance abuse, emotional support.

More models can be found in our Inventory of Local Programs Targeting Complex Patients.

Financing Integrated Models

• How States Can Fund Community Health Workers through Medicaid to Improve People’s Health, Decrease Costs, and Reduce Disparities, Families USA (July 2016). This brief discusses the value of community health workers (CHWs) in improving care while reducing disparities for vulnerable populations. It also walks advocates through how they can get sustainable funding for CHWs in their state.

• Trusted Voices: The Role of Community Health Workers in Health System Transformation, Community Catalyst (November 2015). This Community Catalyst Issue Brief highlights the role community health workers can play in health care delivery, identifies possible means of funding and includes potential partnerships for involving community health workers in health system transformation.

Data Systems for Models