This resource reviews the case for segmenting patients with complex needs and different ways of segmenting, as well as challenges and limitations.
- The high-need, high-cost population is heterogeneous; segmentation helps to match high-need subgroups to interventions that effectively meet their needs.
- There are multiple viable segmentation strategies, depending on purpose. This resource is designed to help health system leaders and payers design and implement interventions and develop workforces to meet the needs of high-need, high-cost patients.
- The draft framework presents six population segments: 1) people under 65 years old with disabilities, 2) frail elders, 3) people with major complex chronic conditions, 4) people with multiple chronic conditions, 5) children with complex needs, and 6) people with advancing illness. However, to effectively match patients to interventions, systems and payers must consider behavioral health conditions and social service needs. This is critical.
- One challenge is limited data sources. It’s ideal to have information from patients, social service agencies, and interoperable systems.
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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
- Why should my organization segment patients with complex needs into subgroups?
- How might a health system or payer approach segmenting high-need patients?
- What does that segmentation look like?
Level of Evidence
Expert OpinionWhat does this mean?