Complex Care Interventions: Building a Sustainable Business Case


By Dr. Todd Staub, Dr. Tom Cheek, and Stephanie Bartz, OptumCare

Complex care interventions, when successful, reduce low-value utilization and meaningfully improve the quality of care for patients with complex illness. Beyond the inherent challenges of implementing these interventions, there is an additional potential road block — building a sustainable business case. Organizations, whether non-profit or for-profit, need a return on investment in order to carry this work forward and continue to invest in innovation.

Those of us that have worked in health care know nothing is straightforward, especially when treating our sickest patients, and this carries over to the interventions we implement, which are often multi-faceted, complex in nature, and resource intensive.

How do we ensure that the costs of these programs are commensurate with the anticipated cost savings? And how can we track success, especially given the time lag between investment and potential savings? As health care providers, getting this right is critical to implementing effective and sustainable complex care interventions.

At OptumCare, we are building a national ambulatory delivery system, led by more than 30,000 physicians who are delivering care locally in communities across the country. We are creating efficient and effective clinical pathways to care for our complex populations in diverse settings. While there are no simple solutions, there are some general considerations and questions we have learned through trial and error and by using the Better Care Playbook that can increase the odds of success.

Understand the data

There is a wise saying from Lean guru Ash Maurya that counsels us to love the problem, not the solution. Gathering data on the patient populations we serve is a key first step, but EMR and claims data are not enough. Demographics, population density, socioeconomics, language, culture, ethnicity, transportation issues, barriers, challenges and community resources are also important; analyzing and processing this knowledge is essential to deeply understand the populations we serve.

Co-create the solution

In the health care industry, many of us are guilty of building elaborate solutions in back rooms, only to be disappointed when the intended recipients of our efforts choose not to engage. To avoid this misstep, OptumCare subscribes to the theory of co-creation — working with the very people, such as patients, families, or clinicians who will eventually utilize the solution, to understand their shared goals, values, and needs. Having a way to incorporate the end-user perspectives into the project plan early saves us from expensive detours that might miss root causes or lack understanding of what truly matters to the people we are serving.

Going one level deeper, it is critical to include physicians in solution design for two reasons. The first being the most obvious — their knowledge and ideas will lead to more effective solutions. The second is less obvious, but arguably equally important. Physicians are skeptical by nature — in fact, it is part of their training. To effectively implement a solution or program for complex patients, they need to believe it is the right thing to do. Involving physicians throughout the planning and implementation process will give them time to process and support the innovation. When ready to launch, their leadership and promotion will encourage adoption by other clinicians.

Furthermore, sometimes we are caught up in daily work and forget the reason we started focusing on the complex patients. A good project team will always lead with purpose — we are serving some of the sickest people in our country, helping them live their best life possible.

Build the right team

We also ensure we have the right people for the right job. People are the most expensive component of complex care interventions. As we form clinical teams, we need to consider which positions to embed locally and which can be drawn from a centralized resource. Also, how much of the intervention needs to be face-to-face and how much virtual? Is there a reasonable mix of the two that produces the desired result while controlling costs? What are the productivity expectations of these teams, and how can we redesign workflows leveraging technology to improve productivity and team dynamics?

Determining needed skill sets and right-sizing teams are important variables. Does the home care team really need a physician? Is there a marginal benefit that justifies the cost of a doctor, or can most of the savings be achieved by a nurse or social worker? What is the best way to add pharmacist skills into the mix or deploy community health workers? Where will a registered nurse be effective and where might we need the additional capabilities of an advanced nurse practitioner?

Earn support from leadership and collaborate with key partners

When health care organizations straddle both inpatient and outpatient worlds, there is an inherent economic conflict in complex care, since most of the cost savings result from reducing hospital care. Resolving this conflict is not easy and having a planned approach to reconcile this issue is important. Collaboration between ambulatory-based providers and hospital partners is critical to achieve high-quality, high-value care.

Bridging the working capital required to stand up these programs until cost savings are realized is often a barrier. It usually takes one to two cycles of a program to get it right, even when implementing best practices that have been successful elsewhere. Published trials do not have enough detail on the logistics of interventions, and even less data on the actual return on investment. For organizations new to this, importing clinical expertise from other markets can help to avoid mistakes up front. Still, those clinical experts will have to recognize key differences in markets that require tactical adaptation.

Because successful implementation can be complex and take time, it is important to set expectations with leadership. Creating a detailed project plan with timing, data collection, measures of success, and estimated cost savings will provide confidence and often lead to funding, if available. Providing leadership with regular progress updates allows for course correction and continued support for the project.

Document both failure and success

Lastly, it is critical to have a methodology to document why some tactics fail and, more importantly, why others are successful. In medicine, we are better at diagnosing why things go wrong and often do not apply the same analytic rigor when things go well. Without a grounded understanding of the elements essential to an intervention’s success, we may miss the mark when rolling out pilots to other sites or miss opportunities to trim waste.

There are many more considerations in building a solid business case for complex care interventions, but we hope that this provides a helpful start. Mastering complex care is a critical step toward broad population health models that serve people at every stage of life, from birth to death. With a sustainable business case for complex care, we can garner the resources needed to pursue a comprehensive population health strategy for all generations over the years and decades ahead.