A Strategic Plan for ‘Radically Different’ Care

By Catherine Mather, Director, Institute for Healthcare Improvement

The field of complex care is still emerging. But where is it headed? The Blueprint for Complex Care, a joint project of the National Center for Complex Health and Social Needs, the Center for Health Care Strategies (CHCS), and the Institute for Healthcare Improvement (IHI), will act as a strategic plan for the emerging field of complex care. The Blueprint will incorporate the input of a diverse set of stakeholders from across the country in order to define the field and create a shared set of priorities for all organizations that will contribute to the field’s development. The Blueprint project is currently in the research phase, and the final document will be available this fall.

In this interview, Mark Humowiecki, Senior Director of the National Center for Complex Health and Social Needs, answered a few questions about the project for the Better Care Playbook blog.

Q: When do you think the field of complex care got its start?

A: It’s tough to pinpoint a moment in time where the field of complex care began — there are many individual innovators and forward-thinking organizations that have been doing the work of complex care for decades without ever using that term. Today’s complex care work stands on the shoulders of pioneers who developed integrated, whole-person models for distinct populations with complex needs — programs like the Program for All-Inclusive Care for the Elderly (PACE) and Housing First.

The broader work of defining and developing the field is more recent. It began as a hypothesis: to provide better care at lower cost to people with complex health and social needs on a national scale, care will need to conceptualized and delivered in a radically different way. To accelerate the adoption of complex care principles, we need to organize ourselves collectively. We are inspired by the Strong Field Framework, developed by the Bridgespan Group and the James Irvine Foundation, which defines a field as “a community of organizations and individuals working together towards a common goal using a set of common approaches to achieving that goal.” The intentional development of the field of complex care will help refine shared goals, identify areas for collective action, organize and disseminate learning and knowledge, develop standards of practice, and promote funding and supportive policies, all of which are essential to changing how we as a society address complex health and social needs.

Q: How do you define complex care, or the people who might benefit from enhanced care programs? What do they have in common, and what differentiates them?

A: Part of the work of the Blueprint is to refine the definition of complex care, and to better define the population that this field serves: people with complex health and social needs or high-cost, high-need consumers. As noted in the recent NAM report, Effective Care for High Need Patients, this population is very heterogeneous, but the combination of total cost, acute utilization, and functional limitations are critical components of a definition. The NAM report also recognizes the importance of behavioral health needs, social barriers, and other factors that correlate to health and health care spending, but that have typically been outside the province of health care systems. The interaction of medical, behavioral health, and social needs creates complexity that the current system is not designed to meet.

Q: What makes complex care programs different from other health care services?

A: Complex care is care that is designed to meet the needs of populations with complex health and social needs. Complex care programs share certain design principles. They are:

  • Data driven. Data is used to identify individuals with complex needs, data is shared between providers, programs are evaluated to achieve continuous improvement, and treatments are evidence-based.
  • Person-centered. Providers cultivate authentic healing relationships, which are secure, genuine, and continuous, and promote individual agency and active health management by participants. They practice trauma-informed care and ensure that the goals and wishes of the participant govern the care plan.
  • Designed to address whole-person needs. Medical, behavioral health, and social needs are addressed either through fully integrated programs, or through well-coordinated partnerships between programs.
  • Designed in partnership with consumers and communities. As the slogan of the disability rights movement says, “nothing about us without us.” People with complex health and social needs are best placed to identify the structural barriers that affect their lives and come up with solutions that work.
  • Transdisciplinary and bridging sectors. Complex care can be found in myriad settings, from hospitals to city jails to participants’ homes, and it challenges traditional assumptions of what health care can or should look like.

Q: What do you hope a strategic plan for the field will accomplish? Which stakeholders are you hoping to influence by laying out a shared agenda?

A: The goals of a strategic plan for the field include better diffusion of innovation and improved efficiency as we work together to build the field of complex care. In the last decade, policy makers, health systems, and payers have increasingly focused on their high-cost, high-need populations, but they have often done so while siloed from each other, and often without enough attention to rigorous program design and evaluation. With the Blueprint, we hope to develop a shared vision of what good complex care looks like and a shared commitment to working in partnership to make that vision a reality through coordinated research, shared frameworks for leadership and workforce development, and replicable models and standards of practice.

Q: What are the biggest barriers or challenges you are anticipating as the field of complex care evolves?

A: Sustainable payment for complex care has been one of the most consistent barriers we’ve seen. Complex care is incompatible with a fee-for-service environment, where it’s almost impossible to make a business case for interventions that decrease utilization and where the incentives favor physician-performed, reactive care instead of the team-based, proactive models of complex care. While the trend toward payment reform is helpful, too many systems remain predominantly in the fee-for-service environment. Moreover, the payment structures for social needs are largely separate and even more complicated to align.

Another challenge involves measuring success. While financial return on investment is important, it is not the only reason to invest in complex care. We need to develop a shared set of metrics that measure the impact of complex care on people’s health and well-being. And health care systems should not be the only ones measuring impact — we need to invest in the infrastructure and capacity of the social service sector to deliver high-quality, evidence-based services and measure their impact on health and well-being.

Finally, complex care challenges traditional boundaries between health care, social services, and other sectors like housing and criminal justice. While the potential to break down silos and develop truly holistic modes of care is exciting, the cross-sector nature of complex care can also lead to turf issues and questions about where the field should be “housed.” Moreover, effective cross-sector collaboration is challenging given the differences in culture, language, and payment models.

Q: Are there examples of other fields that have developed that you’re learning from to help guide your work?

A: As part of the Blueprint research process, we are interviewing pioneers from a range of recently developed fields for lessons and inspiration. Examples within health care include geriatrics, the hospitalist specialization, tobacco control, and trauma-informed care. We’re also looking at widely adopted models like Project ECHO and Housing First.

The National Center for Complex Health and Social Needs has found great inspiration and guidance from the development of the field of palliative care. Diane Meier of the Center to Advance Palliative Care (CAPC) has been an important mentor in the early stages of field-building. There are clear differences between the development of palliative care, which is a service delivery model within most health systems, and complex care, which encompasses multiple models and approaches and aspires to transform how the health care system thinks about the effects of non-medical factors on health. Yet complex care can learn a lot from the ways in which palliative care came together in a coordinated fashion to create a shared leadership development program, invest in field development, and promote the importance of palliative care to health systems and payers.

Q: How does the Playbook relate to the Blueprint work? How can Playbook users help support the Blueprint work?

A: The Playbook and the Blueprint are interrelated and complementary resources, but with distinct purposes and audiences. The Playbook is designed as an interactive resource hub to help health systems, payers, and policymakers begin to understand the needs and root causes of their high-need, high-cost populations and begin to design program and system-level changes to address those needs. The Playbook relies on and harnesses the best evidence in place at this point in time and is critical to accelerating the adoption of complex care.

The Blueprint, on the other hand, is a strategic plan for the next phase of the field, aimed at institutions that are already deeply involved in complex care. The Blueprint work recognizes that the field is still in its early phases, and needs to mature through a directed, collaborative process that values the input of a diverse set of individuals and organizations across the country. We would love the input of Playbook users — it’s the folks who are applying these principles to their work right now who can best tell us what is and isn’t working, and what kind of structure and resources they will need in the coming years. We will be holding open calls for Blueprint input this spring, and hope to hear from both veterans of and newcomers to the field. Contact info@playbook.org to get email updates.

The Blueprint for Complex Care is supported by grants from the Commonwealth Fund, The SCAN Foundation, and the Robert Wood Johnson Foundation, as part of their goal to transform care delivery for chronically ill patients who have the greatest need for health care services. The views presented here are those of the author(s) and not necessarily those of the Foundations, their directors, officers, or staff.