Resources

All programs have to continuously prove themselves as they prototype, implement, expand, and go to scale. Complex care programs often have a lot of stakeholders: senior leaders, payers or other funders, primary care providers, and the field of complex care, among others. Storyboards that include run charts are useful in keeping stakeholders engaged in the program’s results and demonstrating the program’s commitment to data and improvement. They’re also useful in keeping the program team focused on learning. The goal of this play is to help you implement your model, iterate, sustain, and learn...
Patients with complex needs often see multiple providers for different health conditions, including providers in emergency departments, multiple health systems, and in mental health services. Coordinated care plans can help keep all providers informed about the patient’s needs and preferences, helping to coordinate care and decrease waste. While the concept is simple, the implementation of care plans can be challenging. Useful care plans must be concise, goal-oriented, and up-to-date, and there may be no pre-existing way to share care plans within and across health systems. The goal of this...
Evidence has shown that health coaching can help patients improve their health. Health coaching helps patients build the knowledge, skills, and confidence required to manage their chronic conditions. Health coaches empower patients to play a central role in clinical encounters and to engage in self-management activities at home, work, and school, where they spend most of their lives. Therefore, health coaching can play an especially important role for patients with complex needs, who may struggle to manage multiple conditions, providers, and services outside the health system. Training staff...
The payer who is at-risk for the health care costs of the population you serve can be a strong partner in designing enhanced care models for patients with complex needs and high costs. These organizations, whether private health insurers, Medicare or Medicaid plans, hospital systems, or accountable care organizations, likely have their own complex care programs and goals, as well as claims and utilization data useful in designing, measuring, and improving care. If you can demonstrate the value your enhanced care program has in helping them meet their goals, they may be interested in providing...
By Leslie Pelton, Director, Institute for Healthcare Improvement It should be great news. The US knows what kind of care to provide for older adults. We have PACE (Programs of All-Inclusive Care for the Elderly) programs in hospitals and communities, ACE (Acute Care of the Elderly) units in hospitals, and GRACE (Geriatric Resources for Assessment and Care of Elders) in hospitals, for example. The problem is that even though we know what care to provide for older adults, we meet less than 10 percent of the total need in our country with the best evidence-based models of care available. This...
This resource describes the background, strategy, and design of the Creating Age-Friendly Health Systems initiative. In November 2015, The John A. Hartford Foundation determined that a social movement...
This resource describes observations about root causes of high care utilization that emerged from a four-year intervention in a large population of patients with complex needs. In 2012, Mercy Health...
This resource describes the author’s changed understanding of the role of the health system in helping people with complex needs, sparked by an encounter with a vulnerable patient. The author, a nurse...
On December 19, 2017, the Playbook convened payment experts to examine questions many health care organizations are asking: How does my organization get paid to care for the complex health and social...
By the Playbook staff Research has shown that many people with complex health needs are assisted by family members, who often operate as de facto care coordinators. Yet, most care delivery systems don’t proactively identify and meaningfully engage or support family caregivers in visits or care plans. Jennifer Wolff, PhD, is a gerontologist and health services researcher who studies family caregiving and optimal models of care delivery for adults with complex health needs. We asked her a few questions to learn how complex care programs can better engage families in care for patients with...
Since 2015, the Peterson Center on Healthcare has been working to improve the quality and lower the cost of care for high-need, high-cost patients. This resource provides a summary of what has been...
Kevin Barnett, PhD, Senior Investigator Public Health Institute, and Catherine Craig, MPA, MSW, Institute for Health Care Improvement, Triple Aim Faculty More and more, the policy environment is offering opportunities to improve population health, including care for people with complex needs, through cooperative, coordinated efforts. The Affordable Care Act (ACA) and the move to value-based reimbursement provides the impetus and incentive to keep people healthy and out of inpatient acute care settings. The IRS reporting requirements — that tax-exempt hospitals create Community Health Needs...