What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs

September 2016

There is currently no single statement of what a delivery system must have to effectively serve adults with complex care needs. The SCAN Foundation convened a working group of diverse experts representing the interests of adults with complex care needs. This resource describes the output of the group.

  • The group drafted the following overarching goal statement: “Individuals are able to live their lives with services and supports reflecting their values and preferences in the least restrictive, most independent setting possible with access to a delivery system that respects and supports their choices and decisions.”
  • The group identified four essential attributes of a high-quality system of care:
    • Each individual’s range of needs and goals, both medical and non-medical, and the needs of family/caregivers are identified and re-evaluated on an ongoing basis to drive care plans.
    • Each individual’s needs are addressed in a compassionate, meaningful, and person-focused way and incorporated into a care plan that is tailored, safe, and timely.
    • Individuals have a cohesive, easily navigable delivery system. This system allows them to get the services and information they want (by themselves or with support when needed) and avoid the services they do not need or want.
    • Individuals and their family and caregivers continually inform the way the delivery system is structured to ensure that it is addressing their needs and providing resources tailored to them.
  • The group identified the need to address the structure of health care, long-term services and supports, and social service delivery systems in order to comprehensively provide quality support.
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Population Addressed
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
  • What should a delivery system look like in order to serve adults with complex needs?
  • What should its goals and attributes be?
  • What are the challenges to realizing this ideal system?
Level of Evidence
Expert Opinion
What does this mean?