Operational Guide to Identify, Understand, and Treat High-Need Patients

Anne Marie Young
Jesse Singer
Dave Chokshi
Implementation Tool
September 2020


This tool offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.


New York City Health + Hospitals, the largest public health care system in the country, created this guide as a framework to support other safety-net hospitals in identifying, understanding, and treating patients with complex needs.

About this Tool

This guide contains step-by-step information and open-source implementation tools to help safety-net health systems tailor NYC Health + Hospitals approach to meet their own unique needs. The following topics are outlined in the guide:

  • Risk scoring and stratifying data and analytics to identify patients with complex needs;

  • Combining analytics with clinical insight to segment populations to better understand patients with complex needs; and

  • Tailoring care models to fit needs and behaviors of targeted complex populations.

Across each of these topics, the toolkit links to external resources such as predictive modeling tools, patient screeners, and toolkits for provider focus groups to inform the efforts of other health system in creating a holistic segmentation approach for patients with complex needs.


Health systems, particularly safety-net hospitals, may benefit from adapting the guidance and tools in this guide to their efforts to improve risk scoring, stratification, and segmentation in care models for patients with complex needs.

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