Effective Care
for High-Need Patients
Opportunities for Improving Outcomes, Value, and Health
To advance insights and perspectives on how to better manage the care of the high-need patient population, the 91黑料网, with guidance from an expert planning committee, was tasked with convening three workshops held between July 2015 and October 2016. The resulting special publication, Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health, summarizes the presentations, discussions, and relevant literature.
Download Executive Summary Download Key Points5%
of patients account for
NEARLY HALF of the nation鈥檚
spending on health care.
55%
of high鈥搉eed patients
are AGE 65+.
52%
of high鈥搉eed patients鈥� annual
income is BELOW 200% of the
federal poverty level.
Key Takeaway
Improving care for high鈥搉eed patients is not only possible鈥攊t also contributes to a more sustainable health system. But progress will take a coordinated effort from stakeholders including policy makers, payers, providers, and researchers, as well as patients and their loved ones.
Key Characteristics of High-Need Patients
To date, there is no consensus on the defining characteristics of high-need patients.
High-need individuals tend to be disproportionately older, female, white, less educated, publicly insured, have fair to poor self-reported health, and be susceptible to lack of coordination within the health care system.
The needs of this patient population often extend beyond care for their physical ailments to social and behavioral services, which are also important to their overall well-being. To improve outcomes, it will be necessary to address functional, social, and behavioral needs, largely through the provision of social and community services.
Criteria that could form a basis for defining and identifying high-need patients include:
Total accrued health care costs
Intensity of care utilized for a given period of time
Functional limitations, such as limitations in activities of daily living (e.g. dressing) or limitations in instrumental activities of daily living that support an independent lifestyle (e.g. housework)
Opportunities for Action
Improving the care management for high-need individuals will require bold policy action and system and payment reform efforts by a broad range of stakeholders at multiple levels.
How can we all improve and ensure high-quality care for some of our nation鈥檚 most vulnerable patients?
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Health Systems can...
- Work with payers to develop interoperable electronic health records that can include functional and behavioral status and social needs.
- Identify the threshold for targeting programs to those elderly who are frail, since not all elderly need the intensive, coordinated care these programs provide.
- Engage patients and caregivers in design, implementation, and evaluation of care models.
- Work with payers to better identify and target high-need patients and to test new practices and tools.
- Partner with community organizations, including schools and even prisons, as well as with patients, caregivers, and social and behavioral health service providers outside of the health care system to create patient-centered care plans.
- Use established metrics and quality improvement approaches to create an environment of continuous assessment and improvement for these models.
- Assess established culture and promote changes needed to institute new and successful care models, blending medical, social, and behavioral approaches.
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Patients and their Care Partners can...
- Work with care coordinator or care coordination team to amplify self-advocacy efforts and fully utilize care models.
- Participate in active communication with providers regarding quality of care, needs, and services.
- Request formal recognition as part of the care team.
- Seek out formal training and education experiences to enhance care, understand complex medical situations, limit injuries and other errors, and identify problems earlier.
- Explore with a care team the potential benefits of home-based care, including improved financial, social, and psychological outcomes.
- Contribute to the development of quality measures to assist in better decision making around care and care delivery.
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Payers can...
- Actively support the adoption of care models or specific elements of models that research has shown to be effective at improving care for high-need patients.
- Lead efforts to identify and share information about high-need patients and the potential for different models to positively affect the care of those populations.
- Work with policy makers to continue progress toward a value-based system, using alternative payment models, including those that work within a fee-for-service structure, to support more effective care for high-need patients.
- Support recognition, training, and education for patients and caregivers as part of care teams.
- Expect that return on investment for most models of care for high-need patients will take time and that a return in 2 to 3 years is unlikely.
- Develop financing models to provide social and behavioral health services that will both improve care and lower the total cost of care for high-need patients, recognizing that even cost-neutral programs are worth supporting if the outcome is positive for patients.
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Policy Makers can...
- Increase and expand efforts to engage patient and caregiver involvement in discussions around policy options for improving care and reducing costs for high-need patients.
- Modify existing regulations, such as 42 CFR Part II and data-sharing rules in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), to improve data flow among and within agencies and providers.
- Incentivize adoption and use of interoperable electronic health records that include functional, behavioral health, and social factors.
- Harmonize and coordinate Medicare and Medicaid programs to increase access to needed services and to reduce the burden on patients and caregivers.
- Explore the expansion of programs to mitigate financial strain of caregiving, like Medicaid鈥檚 Cash & Counseling.
- Continue payment policy reforms and alignment initiatives to incentivize pay-for-performance instead of fee-for-service.
- Create state- and community-level data-sharing tools which include integrated claims databases that link and share information across payers, service sectors, and provider networks, such as the Predictive Risk Intelligence System (PRISM) that Washington State developed to support care management for high-risk Medicaid patients.
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Providers can...
- Work collaboratively and understand that many successful care models work best when everyone works at the top of their licenses.
- Engage with patients, care partners, and their caregivers in the design and delivery of care.
- Meet patients in their communities or connect patients to community and other social resources and accept that much of the care they will need will be delivered by family and unpaid caregivers or professionals outside the health care system.
- Identify and engage patients鈥� care partners as integrated team participants.
- Fully adopt the proven practices of health literacy to improve patients鈥� and caregivers鈥� ability to follow care plans developed with their input.
- Identify and work to change cultural norms that may hinder adoption of successful care models.
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The Research Community can...
- Gather better data for care models that work, including the effective integration of social and behavioral health services.
- Develop and test a parsimonious set of metrics for measuring outcomes and return on investment for models of care.
- With the involvement of patients, caregivers, and other key stakeholders, continue research on approaches for identifying and segmenting high-need patients in practice settings and matching those individuals with successful care models.
- Identify the best models of care coordination, workforce training, and education for caregivers.
- Study effective culture change implementation techniques to promote spread and scale of successful care models.
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