Using Population Identification Strategies to Tailor Care for Individuals with Complex Needs

May 2021

Traditional approaches to identifying adults with complex health and social needs for care management programs rely on cost, utilization, or clinical patient attributes. However, individuals with complex needs are not homogenous — within this broad category patient needs vary widely, thus a single programmatic approach will likely not benefit everyone. Using data-driven methods to identify unique population subsets can help health care organizations better tailor care interventions to meet a diverse array of patient needs.  

This webinar, coordinated by the Better Care Playbook and made possible through the Seven Foundation Collaborative, featured promising strategies from health systems and payers — including Kaiser Permanente, New York City Health + Hospitals, and CareOregon — for effectively identifying people with complex health and social needs to inform tailored health care interventions for targeted subpopulations. Provider organizations, health systems, health plans, researchers, and other interested stakeholders are invited to join this 90-minute event.


I. Welcome and Introduction

Speakers: Emma Opthof, MPH, CHES, Communications Associate, and Rachel Davis, MPA, Director, Complex Care, Center for Health Care Strategies

E. Opthof welcomed participants and provided an overview of the Better Care Playbook, and R. Davis introduced the panelists and provided a brief introduction to population identification in complex care.  

II. Kaiser Permanente: Using Population Identification Methods to Inform Complex Care Management

Speakers: Anna Davis, PhD, Research Scientist-Investigator, Kaiser Permanente Center for Effectiveness and Safety Research, and Michelle Wong, MPH, MPP, Director, Care Management Institute, Kaiser Permanente

A. Davis described recent research summarizing different methods for identifying patients across the field of complex care and highlighted Kaiser Permanente’s efforts to identify unique clinical profiles among medically complex patients. M. Wong shared how this research has informed the organization’s care management interventions.

III. New York City Health + Hospitals: Employing a System-Wide Tool to Identify and Treat Patients with Complex Needs

Speakers: Anne Marie Young, MBA, Director of Complex Care; and Jillian Diuguid-Gerber, MD, Lead Physician, Woodhull Hospital Primary Care Safety Net Clinic, New York City Health + Hospitals

 A.M. Young provided an overview of New York City Health + Hospitals’ Operational Guide to Identify, Understand, and Treat High-Need Patients, an implementation tool to support health systems in caring for patients with complex needs. J. Diuguid-Gerber described the real-world impact of this tool in one of the health system’s Primary Care Safety Net Clinics.   

IV. CareOregon: Leveraging Data Analytics to Predict Rising Risk Populations within a Managed Care Plan

Speaker: Jonathan Weedman, LPC, CCTP, Vice President, Population Health, CareOregon

J. Weedman described CareOregon’s data segmentation approach for identifying impactable “rising risk” populations — individuals who are on the trajectory to becoming complex, but whose needs and utilization may be stabilized through tailored health care interventions. He discussed the evolution of CareOregon’s approach and outline plans to test interventions to address identified patient risks.

V. Moderated Q&A 

Moderator: Rachel Davis, CHCS

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