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

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.