Ľ«Ć·°×»˘

Loading...

Effective Care
for High-Need Patients

Opportunities for Improving Outcomes, Value, and Health

To advance insights and perspectives on how to better manage the care of the high-need patient population, the National Academy of Medicine, with guidance from an expert planning committee, was tasked with convening three workshops held between July 2015 and October 2016. The resulting special publication, Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health, summarizes the presentations, discussions, and relevant literature.

Download Executive Summary Download Key Points

Featured

5%

of patients account for
NEARLY HALF of the nation’s
spending on health care.

55%

of high–need patients
are AGE 65+.

52%

of high–need patients’ annual
income is BELOW 200% of the
federal poverty level.

Key Takeaway

Improving care for high–need patients is not only possible—it also contributes to a more sustainable health system. But progress will take a coordinated effort from stakeholders including policy makers, payers, providers, and researchers, as well as patients and their loved ones.

Key Characteristics
Patient Taxonomy
Care Models

Key Characteristics of High-Need Patients

To date, there is no consensus on the defining characteristics of high-need patients.

High-need individuals tend to be disproportionately older, female, white, less educated, publicly insured, have fair to poor self-reported health, and be susceptible to lack of coordination within the health care system.

The needs of this patient population often extend beyond care for their physical ailments to social and behavioral services, which are also important to their overall well-being. To improve outcomes, it will be necessary to address functional, social, and behavioral needs, largely through the provision of social and community services.

Criteria that could form a basis for defining and identifying high-need patients include:

  1. Total accrued health care costs

  2. Intensity of care utilized for a given period of time

  3. Functional limitations, such as limitations in activities of daily living (e.g. dressing) or limitations in instrumental activities of daily living that support an independent lifestyle (e.g. housework)

Read Chapter 2 / Key Characteristics of High-Need Patients

Patient & Caregiver Testimonials

  • Special Needs Care Coordinator Relieves Chaos and Gives Quality Time Back to Family

    Melissa W.

    Melissa W. resides in Bloomington, Minnesota and has been involved in Health Care Homes Minnesota as a consumer site visit evaluator, a member of Health Care Homes’ advisory committee, and numerous other health advocacy boards. Her son Devin, born with a chromosome disorder in 1996, is medically complex and developmentally delayed. This is Melissa and Devin’s story....

    Read More
  • Individualized Care Helps Patient Return to His Passion for Music and Exercise

    Mike G.

    Mike is former U.S. Marine and youth athletics coach in Massachusetts who has faced multiple chronic health issues over the past several years, including cancer, congestive heart failure, and the loss of one of his legs. The father of two grown children, Mike’s condition required him to....

    Read More
  • A Whole-Person-Centered Approach to Care Gives Family a Solid Foundation to Care for Child with Complex Needs

    Marcella C.

    Marcella C. resides in Annandale, VA with her husband, son, and daughter. Her daughter was hospitalized upon birth for a congenital defect that required an extensive stay in the Neonatal Intensive Care Unit at Children’s National Medical Center. She was discharged from the NICU at 7 months old with....

    Read More
  • Nurse Care Coordinator Helps Family Navigate Complex Care System

    Lisa W.

    Originally from Wisconsin, Lisa W. moved to Mankato, Minnesota for graduate school and she and her husband Scott then chose to make Mankato home for their family of four boys and 2 dogs. Their oldest son, Konnor, was born with congenital hydrocephalus and has since been diagnosed with....

    Read More
  • Whole-Person Approach to Care Helps Daughter Defy the Odds

    TjaMeika D.

    TjaMeika D. resides in District Heights, Maryland with her husband and their three daughters. Her second daughter has a rare epilepsy syndrome, autism, intellectual disability, gait anomaly, and other health issues as a result of being born with an extremely rare chromosomal rearrangement....

    Read More
  • Whole-Person Approach to Care Provides Family a Roadmap to Peace of Mind

    Darcel J.

    Darcel J. resides in Temple Hills, MD with her husband Marc, stepson Byron, and wonderfully-made daughter Anniyah, who has complex health needs. For the last 11 years, the Complex Care Program at Children’s National Health System has provided a medical home for Anniyah, providing patient and family centered, coordinated, compassionate, and comprehensive care. This outstanding program has helped optimize Anniyah’s care, allowing Darcel and her family to do what matters most: Integrate Anniyah into home and community so she can live her best life....

    Read More
  • Coordinated Care Acts as a “Beautifully Orchestrated Symphony” and Provides Family Hope for the Future

    Brandon G.

    Brandon G. resides in Hayward, California with his wife Diana and cat Sophie. Brandon was diagnosed in 2015 with a rare genetic condition known as Vascular Ehlers Danlos. While this condition has resulted in a significant change to Brandon’s active lifestyle, he and his wife still find ways to have fun and explore the beautiful state of California....

    Read More
  • Coordinated Care Program Empowers Patient to be Active Participant in Care After Cancer

    Guadalupe M.

    Guadalupe has worked at Stanford for 14 years. In 2015, she was diagnosed with stage 2 breast cancer. Stanford Coordinated Care, designed for Stanford employees, provided the best compassionate managed care that allowed her to feel reassured and focus on her life-changing decisions....

    Read More
  • Coordinated Care Program Helps Patient Heal from Trauma and Gives Her a New Lease on Life

    Theresa

    Theresa is a native of the San Francisco Bay Area and has experienced emotional trauma throughout her life. She lost a parent at the age of 7, experienced verbal and physical abuse by her mother, and had a sister with a mental handicap. Combined, this trauma resulted in Theresa experiencing severe self-loathing and very low self-esteem for many years. Not long ago, Theresa was connected to Stanford’s Coordinated Care Program which has allowed her to take back control of her health and her life. She now looks forward to the future more than she ever has, including moments like dancing at her daughter’s wedding.....

    Read More
  • Care Coordinator Provides Mother Actionable Plan for Child with Complex Needs

    Katie S.

    Katie S. resides is Minneapolis, Minnesota, with her husband, 14 year old son, and 9 year old daughter. Southlake Pediatrics and Health Care Homes has helped her navigate her daughter’s non-verbal learning disability and other challenges that come with this diagnosis....

    Read More
  • Nurse Care Manager Brings Dignity and Newfound Relief for Family

    Claire M.

    Claire M. is the daughter of Nora M., a participant of Health Quality Partners (HQP) in Pennsylvania. Claire is largely responsible for Nora’s care. The National Academy of Medicine spoke with Claire about Health Quality Partners’ role in Nora’s care and how their nurse care manager has relieved stress and anxiety for Claire....

    Read More
  • Exercise Program and Nurse Care Manager Equip Couple with Skills and Knowledge to Remain Living at Home Longer

    Robert and Jacqueline P.

    Robert P, 95, is a participant in Health Quality Partners in Pennsylvania. Robert and his wife, Jacqueline have lived in the same house for nearly 45 years. The National Academy of Medicine spoke with Robert and Jacqueline about Health Quality Partners’ role in Robert’s care and how their exercise program and nurse care manager have provided invaluable information and insights over the past few years so Robert and Jacqueline can continue living in their home together....

    Read More
  • Exercise and Nutrition Guidance Proves Invaluable for Preventative Care

    Richard D.

    Richard D., a former insurance executive who was in charge of both traditional and managed care, is a participant in Health Quality Partners, a Pennsylvania non-profit research and development organization committed to designing, testing, and disseminating effective systems of preventative care. Richard has dealt with a myriad of health conditions over the past few decades, including a heart attack, diabetes, and cancer. The National Academy of Medicine spoke with Richard about how Health Quality Partners’ exercise and nutrition education program helped Richard lose weight, gain control of his diabetes, and develop healthier eating habits to sustain a longer, healthier life....

    Read More

    Opportunities for Action

    Improving the care management for high-need individuals will require bold policy action and system and payment reform efforts by a broad range of stakeholders at multiple levels.

    How can we all improve and ensure high-quality care for some of our nation’s most vulnerable patients?

    Read Chapter 6 / Common Themes and Opportunities for Action

    • Health Systems can...
      • Work with payers to develop interoperable electronic health records that can include functional and behavioral status and social needs.
      • Identify the threshold for targeting programs to those elderly who are frail, since not all elderly need the intensive, coordinated care these programs provide.
      • Engage patients and caregivers in design, implementation, and evaluation of care models.
      • Work with payers to better identify and target high-need patients and to test new practices and tools.
      • Partner with community organizations, including schools and even prisons, as well as with patients, caregivers, and social and behavioral health service providers outside of the health care system to create patient-centered care plans.
      • Use established metrics and quality improvement approaches to create an environment of continuous assessment and improvement for these models.
      • Assess established culture and promote changes needed to institute new and successful care models, blending medical, social, and behavioral approaches.

      Download Health Systems Stakeholder Brief

    • Patients and their Care Partners can...
      • Work with care coordinator or care coordination team to amplify self-advocacy efforts and fully utilize care models.
      • Participate in active communication with providers regarding quality of care, needs, and services.
      • Request formal recognition as part of the care team.
      • Seek out formal training and education experiences to enhance care, understand complex medical situations, limit injuries and other errors, and identify problems earlier.
      • Explore with a care team the potential benefits of home-based care, including improved financial, social, and psychological outcomes.
      • Contribute to the development of quality measures to assist in better decision making around care and care delivery.

      Download Patients and their Partners Stakeholder Brief

    • Payers can...
      • Actively support the adoption of care models or specific elements of models that research has shown to be effective at improving care for high-need patients.
      • Lead efforts to identify and share information about high-need patients and the potential for different models to positively affect the care of those populations.
      • Work with policy makers to continue progress toward a value-based system, using alternative payment models, including those that work within a fee-for-service structure, to support more effective care for high-need patients.
      • Support recognition, training, and education for patients and caregivers as part of care teams.
      • Expect that return on investment for most models of care for high-need patients will take time and that a return in 2 to 3 years is unlikely.
      • Develop financing models to provide social and behavioral health services that will both improve care and lower the total cost of care for high-need patients, recognizing that even cost-neutral programs are worth supporting if the outcome is positive for patients.

      Download Payers Stakeholder Brief

    • Policy Makers can...
      • Increase and expand efforts to engage patient and caregiver involvement in discussions around policy options for improving care and reducing costs for high-need patients.
      • Modify existing regulations, such as 42 CFR Part II and data-sharing rules in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), to improve data flow among and within agencies and providers.
      • Incentivize adoption and use of interoperable electronic health records that include functional, behavioral health, and social factors.
      • Harmonize and coordinate Medicare and Medicaid programs to increase access to needed services and to reduce the burden on patients and caregivers.
      • Explore the expansion of programs to mitigate financial strain of caregiving, like Medicaid’s Cash & Counseling.
      • Continue payment policy reforms and alignment initiatives to incentivize pay-for-performance instead of fee-for-service.
      • Create state- and community-level data-sharing tools which include integrated claims databases that link and share information across payers, service sectors, and provider networks, such as the Predictive Risk Intelligence System (PRISM) that Washington State developed to support care management for high-risk Medicaid patients.

      Download Policy Makers Stakeholder Brief

    • Providers can...
      • Work collaboratively and understand that many successful care models work best when everyone works at the top of their licenses.
      • Engage with patients, care partners, and their caregivers in the design and delivery of care.
      • Meet patients in their communities or connect patients to community and other social resources and accept that much of the care they will need will be delivered by family and unpaid caregivers or professionals outside the health care system.
      • Identify and engage patients’ care partners as integrated team participants.
      • Fully adopt the proven practices of health literacy to improve patients’ and caregivers’ ability to follow care plans developed with their input.
      • Identify and work to change cultural norms that may hinder adoption of successful care models.

      Download Providers Stakeholder Brief

    • The Research Community can...
      • Gather better data for care models that work, including the effective integration of social and behavioral health services.
      • Develop and test a parsimonious set of metrics for measuring outcomes and return on investment for models of care.
      • With the involvement of patients, caregivers, and other key stakeholders, continue research on approaches for identifying and segmenting high-need patients in practice settings and matching those individuals with successful care models.
      • Identify the best models of care coordination, workforce training, and education for caregivers.
      • Study effective culture change implementation techniques to promote spread and scale of successful care models.

      Download Research Community Stakeholder Brief

    Resources

    Webinar Series

    The National Academy of Medicine hosted a webinar series to provide insight on the components of successful models of care for specific groups of high-need patients. The webinar series featured programs across the country that have seen success in their efforts to improve care and outcomes for high-need individuals. The webinar series helped glean useful lessons learned and considerations for spreading and scaling successful programs. The series provided clear and actionable impetus for health system leaders, front-line clinicians, researchers, policy makers, and patient and family caregivers, among others, to actively work to improve care for high-need patients in their local communities.

    Webinar with Commonwealth Care Alliance

    , a not-for-profit, community-based health care organization shared their experience implementing the to improve care for dually eligible individuals under age 65 with complex medical, behavioral health, and social needs. The webinar included a robust discussion with Commonwealth Care Alliance about the practical challenges they have faced in implementing their program, impact on patient outcomes, and opportunities for scaling and spreading.

    Webinar with Health Quality Partners

    , a Pennsylvania-based not-for-profit research and development organization, employs an advanced preventative care model targeting elderly complex patients. The webinar explored their efforts to refine and tailor their model to incorporate coordinated care, health education, and self-management of care, as well as challenges and successes in the spread and scale of the model.

    Webinar with Health Share of Oregon

    , a Portland-based coordinated care organization, discussed their work to improve care for high-need patients. The conversation highlighted unique aspects of their models of care for children with complex needs and for children in foster care, their work to link medical care with community services, and their efforts and successes in the spread and scale of their model.

    Workshop Series

    Sponsored by the Peterson Center on Healthcare, the National Academy of Medicine held three public workshops and a special publication release event to engage stakeholders in a discussion of the issues, challenges, and approaches that present the greatest opportunity to creating models of care for high-need patients. Robust discussions throughout the workshop series informed the final Special Publication in which the planning committee explores how to better serve high-need individuals, improve their health outcomes, and reduce costs.

    Publication Release Event

    The National Academy of Medicine held a public meeting to formally launch the special publication, which summarizes the findings from the three-part workshop series. The meeting also provided an opportunity to discuss action priorities for improving the effectiveness and efficiency of care for high-need patients.

    Workshop 1

    Workshop 2

    Workshop 3

    Better Care Playbook

    Sponsored by the Peterson Center on Healthcare, the National Academy of Medicine held three public workshops and a special publication release event to engage stakeholders in a discussion of the issues, challenges, and approaches that present the greatest opportunity to creating models of care for high-need patients. Robust discussions throughout the workshop series informed the final Special Publication in which the planning committee explores how to better serve high-need individuals, improve their health outcomes, and reduce costs.

    Resources

    Webinar Series

    Building Effective Care for High-Need Patients, the National Academy of Medicine hosted a webinar series to provide insight on the components of successful models of care for specific groups of high-need patients.

    The webinar series featured programs across the country that have seen success in their efforts to improve care and outcomes for high-need individuals. The webinar series helped glean useful lessons learned and considerations for spreading and scaling successful programs. The series provided clear and actionable impetus for health system leaders, front-line clinicians, researchers, policymakers, and patient and family caregivers, among others, to actively work to improve care for high-need patients in their local communities.

    • Webinar with Commonwealth Care Alliance

      , a not-for-profit, community-based health care organization shared their experience implementing the to improve care for dually eligible individuals under age 65 with complex medical, behavioral health, and social needs. The webinar included a robust discussion with Commonwealth Care Alliance about the practical challenges they have faced in implementing their program, impact on patient outcomes, and opportunities for scaling and spreading.

    • Webinar with Health Quality Partners

      , a Pennsylvania-based not-for-profit research and development organization employs an advanced preventative care model targeting elderly complex patients. The webinar explored their efforts to refine and tailor their model to incorporate coordinated care, health education, and self-management of care, as well as challenges and successes in the spread and scale of the model.

    • Webinar with Health Share of Oregon

      , a Portland-based coordinated care organization, discussed their work to improve care for high-need patients. The conversation highlighted unique aspects of their models of care for children with complex needs and for children in foster care, their work to link medical care with community services, and their efforts and successes in the spread and scale of their model.

    • Webinar with Health Share of Oregon

      , a Portland-based coordinated care organization, discussed their work to improve care for high-need patients. The conversation highlighted unique aspects of their models of care for children with complex needs and for children in foster care, their work to link medical care with community services, and their efforts and successes in the spread and scale of their model.

    Workshop Series

    Building on the Special Publication focusing on Effective Care for High-Need Patients, the National Academy of Medicine hosted a webinar series to provide insight on the components of successful models of care for specific groups of high-need patients by featuring programs across the country that have seen success in their efforts to improve care.

    Associated Publications

    Annals of Internal Medicine

    The Hill

    Health Affairs

    Health Affairs

    JAMA Forum

    Fierce Healthcare

    Expert Q&A, Drs. Peter Long and Danielle Whicher

    Video Presentation, Dr. Jose Figueroa

    Health Affairs

    About

    Sponsorship

    This project was made possible with funding from the .

    The is part of a six-foundation partnership working together to accelerate health system transformation and to maximize their individual investments and avoid duplication in efforts to scale and spread promising care models for high-need patients. This six-foundation partnership includes , , the , the , and .

    Planning Committee for the Workshop Series

    Peter V. Long (Chair)

    President and Chief Executive Officer, Blue Shield of California Foundation

    Melinda K. Abrams

    Vice President, Delivery System Reform, The Commonwealth Fund

    Gerard F. Anderson

    Director, Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public Health

    Tim Engelhardt

    Director, Federal Coordinated Health Care Office, Centers for Medicare & Medicaid Services

    Jose Figueroa

    Instructor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women’s Hospital

    Katherine Hayes

    Director, Health Policy, Bipartisan Policy Center

    Frederick Isasi

    Executive Director, Families USA; former Health Division Director, National Governors Association

    Ashish K. Jha

    K. T. Li Professor of International Health & Health Policy, Director, Harvard Global Health Institute, Harvard T.H. Chan School of Public Health

    David Meyers

    Chief Medical Officer, Agency for Healthcare Research and Quality

    Arnold S. Milstein

    Professor of Medicine, Director, Clinical Excellence Research Center, Center for Advanced Study in the Behavioral Sciences; Stanford University

    Diane Stewart

    Senior Director, Pacific Business Group on Health

    Sandra Wilkniss

    Program Director, Health Division, National Governors Association

    Taxonomy Workgroup

    Melinda K. Abrams

    Vice President, Delivery System Reform, The Commonwealth Fund

    Gerard F. Anderson

    Director, Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public Health

    Melinda J. Beeuwkes Buntin

    Chair, Department of Health Policy, Vanderbilt University School of Medicine

    Dave A. Chokshi

    Assistant Vice President, New York City Health and Hospitals Corporation

    Henry Claypool

    Policy Director, Community Living Policy Center University of California San Francisco

    David A. Dorr

    Professor & Vice Chair, Medical Informatics, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University

    Jose Figueroa

    Instructor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women’s Hospital

    Ashish K. Jha

    K.T. Li Professor of International Health and Health Policy, Director, Harvard Global Health Institute, Harvard T.H. Chan School of Public Health

    David Labby

    Founding Chief Medical Officer & Health Strategy Adviser, Health Share of Oregon

    Prabhjot Singh

    Director, Arnhold Institute for Global Health, Mount Sinai Health System

    Policy Workgroup

    Gerard F. Anderson

    Director, Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public Health

    Tim Engelhardt

    Director, Federal Coordinated Health Care Office, Centers for Medicare & Medicaid Services

    Katherine Hayes

    Director, Health Policy, Bipartisan Policy Center

    Sandra Wilkniss

    Program Director, Health Division, National Governors Association

    Contact Information

    Henrietta Osei-Anto

    Senior Program Officer

    NAMedicine@nas.edu