Effective Care for High-Need Patients: Opportunities for Improving Value, Outcomes and Health

Authors
Peter Long
Melinda Abrams
Arnold Milstein
Gerald Anderson
Katherine Lewis Apton
Maria Lund Dahlberg
Danielle Whicher
Brief/Report
June 2017

This resource is the product of a collaborative assessment on strategies for better serving high-need patients convened by the National Academy of Medicine (NAM). Activities included workshops, a literature review, and a synthesis of the work and proceedings.

Key points include:

  • The high-need population is disproportionately older, female, white, less educated, and more likely to be publicly insured.
  • A taxonomy of high-need patients can help match the appropriate care model or care team with particular patient segments. This paper includes a preliminary “starter taxonomy” that can be further refined.
  • The most successful programs focus on either a targeted age group with broad combinations of diagnoses or individuals classified as high-utilizers.
  • Features of successful organizational culture include leadership engagement, customization to the local context, strong team relationships, appropriate training, continuous assessment, and the use of multiple sources of data.
  • An opportunity for progress in better serving high-need patients could come from combining Medicare and Medicaid funding streams for dual-eligible patients into an integrated, flexible structure to address the full range of patient needs.
  • Academic health centers and professional societies should collaborate on developing new training and certification opportunities that focus on the treatment and social support needs of high-need patients.

 

 

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Key Questions Answered
  • How can the high-need population be identified, defined, and usefully segmented?
  • What are some common features of successful models of care for high-need individuals?
  • What are some opportunities for improving policy to address the needs of these patients?