Using segmentation to address clinical and social needs for Medicaid patients with complex needs and costly utilization can improve the effectiveness of complex care programs.
Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.
Describes core competencies that convey the essential knowledge, skills, and attitudes of complex care practitioners and teams to improve care for people with complex needs.
Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.
This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.
Accountable care organizations must address key funding, community partnership, and data sharing requirements to successfully integrate social services into medical care.