The National Academy of Medicine has published a report on effective care for high-need patients, highlighting the opportunities for improving outcomes, value, and health. In the U.S., 1% of patients account for more than 20% of the nation’s health care expenditures, and 5% account for nearly half of the nation’s spending on health care.

Significantly, the report does not identify high-need patients based solely on medical conditions but proposes a taxonomy that embeds social risk factors, behavioral health factors, and functional limitations to identify high-need patients. Patients would first be identified through a clinical assessment, with follow-on assessment of behavioral health issues and social services needs to determine the specific type of services are required. For example, key behavioral health factors most likely to affect care delivery decisions include substance abuse, serious mental illness, cognitive decline, and chronic toxic stress. Key social risk factors include low socioeconomic status, social isolation, community deprivation, and house insecurity.

Accordingly, groups of high-need patients would include:

  • Children with complex needs: have sustained severe impairment in at least four categories together with enteral/parenteral feeding or sustained severe impairment in at least two categories and requiring ventilation or continuous positive airway pressurea tinuous positive airway pressure
  • Non-elderly disabled: under 65 years and with end-stage renal disease or disability based on receiving Supplemental Security Income
  • Multiple chronic conditions: one complex condition and/or between one and five noncomplex conditions
  • Major complex chronic conditions: two or more complex conditions or at least six noncomplex conditions
  • Frail elderly: over 65 years and with two or more frailty indicators
  • Advancing illness: other terminal illness, or end of life

The report reviewed over a dozen models of care and identifies the following care attributes of successful models of care of high-need patients:

  • Assessment: multidimensional (medical, functional, and social) patient assessment
  • Targeting: targeting those most likely to benefit
  • Planning: evidence-based care planning
  • Alignment: care match with patient goals and functional needs
  • Training: patient and care partner engagement, education, and coaching
  • Communication: coordination of care and communication among and between patient and care team
  • Monitoring: patient monitoring
  • Linking: facilitation of transitions

And here are the delivery features of successful models of care:

  • Teamwork: multidisciplinary care teams with a single, trained care coordinator as the communication hub and leader
  • Coordination: extensive outreach and interaction among patient, care coordinator, and care team, with an emphasis on face-to-face encounters among all parties and colloca- tion of teams
  • Responsiveness: speedy provider responsiveness to patients and 24/7 availability
  • Feedback: timely clinician feedback and data for remote patient monitoring
  • Medication management: careful medication management and reconciliation, particularly in the home setting
  • Outreach: extension of care to the community and home
  • Integration: linkage to social services
  • Follow-up. Prompt outpatient follow-up after hospital stays and the implementation ofstandard discharge protocols

An executive summary and summary of key points are available. In addition, a two-page summary of characteristics of successful models of care for high-need patients also is available.



Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s