Using Patient Segmentation and Data on Health-Related Social Needs to Identify People with Complex Needs

October 2021

Efforts to improve health care services and limit preventable spending often focus on people who are likely to become the sickest. Because the needs of people with complex health and social needs are diverse, health care stakeholders need ways to segment patient subgroups and tailor strategies to engage patients who are most at risk for experiencing potentially avoidable care or poor health outcomes. Recent work supported by The Commonwealth Fund and led by Jose Figueroa, MD, MPH at the Harvard T.H. Chan School of Public Health, in collaboration with the Institute for Accountable Care, suggests that segmenting patients with complex needs into smaller, meaningful subgroups can help guide which interventions may be more effective for specific people.

This Better Care Playbook webinar, made possible through the Seven Foundation Collaborative, explored how health care organizations can incorporate a segmentation framework into population health management using simple algorithms. Speakers discussed how incorporating health-related social needs data into population health management tools can help organizations design tailored care models to engage patients most at risk for poor outcomes.

In addition to describing the segmentation framework, this webinar featured representatives from two health insurers that are using data in new ways to better engage patients with complex needs ― Humana and Point32Health. Speakers outlined how they have incorporated principles of segmentation and social risk to develop actionable interventions for specific patient cohorts.


I. Welcome and Introduction

Speaker: Karla Silverman, MS, RN, CNM, Associate Director, Complex Care Delivery, Center for Health Care Strategies (CHCS)

K. Silverman provided an overview of the Better Care Playbook and a brief introduction to population segmentation in complex care.  

II. Using Segmentation Frameworks to Identify Patients with Complex Needs

Speaker: Jose Figueroa, MD, MPH, Assistant Professor of Health Policy and Management, Harvard T.H. Chan School of Public Health; Assistant Professor of Medicine, Brigham and Women's Hospital

J. Figueroa described the development of a segmentation framework that uses simple algorithms to identify clinically relevant high-need, high-cost sub-populations. These algorithms are publicly available for organizations that are interested in adapting similar segmentation approaches.

III. Point32Health: Developing a Patient Dashboard to Drive Organizational Strategy

Speaker: Louis Cabanilla, MSc, Director of Clinical Analytics, Point32Health

L. Cabanilla described how Point32Health (the parent organization for the Tufts Health Plan and Harvard Pilgrim Health Care) has applied a high-need, high-cost segmentation framework and developed a patient dashboard to inform organizational initiatives and interventions.

IV. Humana: Integration of Social Determinants of Health Data

Speaker: Andrew Renda, MD, MPH, Vice President, Bold Goal and Population Health Strategy, Humana

A. Renda discussed Humana’s “Bold Goal” and discuss how they are integrating data on social determinants of health into their daily operations to generate insights, strategies, and interventions to improve the health of populations with complex health and social needs.

V. Moderated Q&A 

Moderator: Karla Silverman, CHCS

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