Who are people with complex needs?
High-need individuals have clinically complex needs, functional limitations, and/or behavioral health conditions, and incur high health care costs or are likely to in the near future. This is a diverse population, ranging from frail older adults to people with behavioral health and social needs.
Rates of hospitalizations, emergency department visits, and home health services are significantly higher for these individuals than the nation at large. However, despite higher utilization and associated spending, they are significantly more likely to report unmet needs.
There is no “one-size-fits-all” approach to support people with complex needs. To effectively meet their needs, the first step is for providers to identify subgroups (or segments) with similar needs and/or service use patterns in order to tailor interventions appropriately.
The population subgroups identified in the Playbook were derived from work by the National Academies of Medicine (NAM).
Digging Deeper
Use the links on the right to find additional resources about managing care for people with complex needs.
How do I identify my complex needs population?
There are different strategies to segment complex needs populations. Some begin with stratifying the whole patient population to identify those with high needs, high costs, or high utilization. Others analyze administrative and clinical data to predict which individuals are most likely to be frequent users of costly health care services. Health systems and providers can then segment this group by the complexity, types of conditions, or care needs. However, few take into account socioeconomic characteristics, functional limitations, or other factors that have bearing on health outcomes, which some experts feel are core to segmentation.
How do I make care more responsive to the person's needs?
People with complex needs often report dissatisfaction with health care services they receive. Positive experiences are often correlated with higher quality care, but programs often fail to incorporate patient experience as an improvement goal. Authentic communication with people and their family caregivers is critical for engaging them in decision-making, care planning, treatment adherence, and self-management.