Recently, the National Academy of Medicine (NAM) convened experts and stakeholders to explore the key attributes of patients with complex needs and devise a course of action for improving care for this patient population. Peter Long, PhD, President and CEO, Blue Shield of California Foundation and Chair of the workgroup, and Danielle Whicher, PhD, MHS, Senior Program Officer, National Academy of Medicine, worked with a team of experts to craft the NAM special publication, Effective Care for High-Need Patients: Opportunities for Improving Value, Outcomes, and Health. We asked them to share insights and guidance on how to use findings from the recently released publication.
What did you learn about successful care models for patients with complex needs?
LONG: The care setting is very important, and it’s important to consider where the care model is happening and how behavioral and social needs are taken into account. We also learned that providers can use “functional status” (or how well individuals manage daily routines) as a barometer for how people are doing in life and target those individuals with specific, customized care. This is why segmenting patients and then matching the model of care to the patient is important.
How can information on successful care models be used by health system leaders?
LONG: If I had to pick one thing, I would urge health systems to move with speed toward value-based payment. We discussed how linking is an important component of a successful model of care for high-need patients. Some of these links are not traditionally found in the electronic health record. A health system can have a robust data system that allows information to be shared around these assets. So really, there are two plays a health system can take: focus on a value-based financing model and work on the data — it’s the life blood in terms of reinforcing linkages.
What would you say is the most salient information from this special publication for policymakers? Can you identify any opportunities for policymakers to improve care for high-need patients?
WHICHER: We need to incentivize patient-centered care. The provision of social support services, as well as behavioral support services, is really important. Another piece is technology. There needs to be data, so that systems can use it to segment the population. Right now, the data infrastructure isn’t where it needs to be and doesn’t integrate information on socioeconomic status — something that is critical to making care decisions.
LONG: Even if you wanted to do some of this work, current polices inhibit handoffs and coordination, so putting together value-based payment, aligning the regulatory framework so that it is patient-centered, and creating outcome measures that matter — the extent to which policy can put these together would accelerate progress.
What opportunities are there for others in this special publication?
WHICHER: We’ve discussed the need for training, and there’s a lot of opportunity for professional societies and academic health centers. There’s an opportunity to build a workforce that can deliver coordinated, team-based care.
Are there other practical lessons you’d like to share?
LONG: Sometimes, we are waiting for the ‘perfect’ to do something. We know a tremendous amount about how to take care of this population well, but we are waiting for the perfect answer or thinking that somehow there’s going to be a new policy that’s going to fix it. It’s through hundreds of minor changes and empirical learning that we’ve come this far. We have a lot of tools that do work and are working, and the real beauty, the ‘special sauce,’ has been iteration. The value in this special publication, and in the Playbook, is aggregating what folks have been trying — both good and bad. That’s the real secret sauce.
What are some resources for individuals interested in additional reading on key themes from the special publication?
WHICHER: For further reading on patient segmentation and different care models, folks should read “A Bipartisan “Moonshot” in Health: Improving Care for High-Need Patients” and “An Untapped Opportunity For Health Care Progress: Redesigning Care For High-Need Patients.”