Academic Medical Centers and High-Need, High-Cost Patients: A Call to Action

David Blumenthal
Douglas McCarthy
Tanya Shah
Journal Article
November 2018

This resource reviews efforts of academic medical centers (AMCs) to improve care for patients with complex needs, and the opportunities for AMCs to contribute to better care throughout the health system.

  • More AMCs are seeking to improve care for patients with complex needs, in part because value-based payment models make it financially beneficial.
  • Six key program features have proven results for improving care for this population, including targeting interventions to those patients who are most likely to benefit; comprehensively assessing patients’ needs; and partnering with social service providers to address patients’ non-clinical needs.

AMCs have a critical role to play in influencing the nation’s next generation of medical professionals, by teaching them to address the social determinants of health, work in team-based environments, and effectively communicate with patients

Posted to The Playbook on
Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • How have academic medical centers (AMCs) been working to improve care for patients with complex needs?
  • What features do successful programs have in common?
  • What role can AMCs play in reshaping the health system to address patients with complex needs?
Level of Evidence
Expert Opinion
What does this mean?