Play by Play

Perspectives from leaders in the field of complex care.


By David Blumenthal, MD, MPP, President, The Commonwealth Fund, and Tanya Shah, MBA, MPH, Assistant Vice President, Delivery System Reform, The Commonwealth Fund

The dialogue on caring for patients with complex needs has moved beyond a recognition that social factors like housing or nutrition have an outsize impact on health to practicalities. Now, health care providers are asking: what can we actually do to help?

Caring for the complex chronically ill — a population that makes up about 5 percent of patients and nearly 50 percent of health care spending — is remarkably challenging. It’s also essential, as the United States transitions to a health care system that is driven by value.

If you’ve seen how quickly a relatively mobile older adult can turn into a frail and bedbound patient — not because of a primary illness, but because of a lack of movement — then you can appreciate how dramatically different care is at Saint Joseph Mercy Health System in southeast Michigan, and Anne Arundel Medical Center in Annapolis, Maryland.

The program, known as Community Aging in Place — Advancing Better Living for Elders (CAPABLE), is a client-directed home-based intervention to increase mobility, functionality, and capacity to “age in place” for older adults.
Many studies have highlighted the importance of effective interprofessional care teams to improve health outcomes for people with complex needs. But many programs do not take advantage of the special training of social workers to meet these needs on their primary health care teams.

By Corey Waller, Better Care Playbook Faculty and Principal at Health Management Associates

I currently do some work as a locum tenens physician in the emergency department, filling in during staff shortages. In this capacity, I get to work in a few different hospital systems around the country. No matter which one I go to, I can count on the fundamental aspects of basic cardiac care to be delineated no matter where I am.

Addiction is a chronic neurobiological disorder that is predictable, identifiable, and treatable. Dr. Corey Waller explains why evidence-based treatment needs to be in hospitals, primary care, stand-alone rehabs, and throughout the ecosystem of health care.