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

Peter Long
Melinda Abrams
Arnold Milstein
Gerald Anderson
Katherine Lewis Apton
Maria Lund Dahlberg
Danielle Whicher
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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