Rachel Davis, MPA and Teagan Kuruna, MPH

November 19, 2015

“Learning the medicine is what doctors do when they’re young . . . over time, it becomes important to figure out how to disrupt systems to get patients the other things they need.” 

Karen Nelson, MD, MPH, Maimonides Medical Center

With increasing focus across the health care delivery system on how to better serve high-need, high-cost patients, providers play a key role in re-engineering care delivery at both the clinical and systems levels. Yet, how prepared are today’s clinicians – particularly those early in their careers – to address the complex non-medical needs of this hard-to-serve population?

Innovation Lab NotesAs models for improving care for high-need, high-cost populations continue to emerge, we looked for advice from members of the Complex Care Innovation Lab, a national initiative, coordinated by the Center for Health Care Strategies and supported by Kaiser Permanente Community Benefit. The Innovation Lab brings together providers at the vanguard of improving care for low-income patients with complex medical and social needs to learn from each other’s experiences.

Below are insights from our conversations with select Innovation Lab members who shared what they wished they had known before getting started in complex care:

Partner with social services to help address patients’ complex needs

“We used to treat people and send them home, but the gap between treating people and sending them home is a chasm,” says Karen Nelson, MD, MPH, senior vice president, integrated delivery systems, Maimonides Medical Center. Addressing the social determinants of health — the circumstances in which a person lives and the larger societal forces that shape people’s lives — is no longer optional. Individuals with complex needs often have complicated medical issues in addition to experiencing unstable housing, insecure access to food, and unemployment. Realizing that their patients’ medical concerns are intensified by these challenges, those who work with complex patients often need to make connections with social services and other systems. At the Brooklyn Health Home, led by Maimonides Medical Center, care navigators work closely with social services to help patients who may be dealing with eviction, jail admission, or job training needs.

Find ways for high-touch care and cost effectiveness to co-exist

“Much of what we do is not taught in medical school or residency, particularly the value of how to link quality and cost outcomes in patient care,” says Toyin Ajayi, MD, chief of medicine, Commonwealth Care Alliance. As a result, physicians who work with complex patients often need to learn on the job and embrace innovative strategies to marry high-touch care and cost-effectiveness. Through tailored, high-touch health care partnerships with social service agencies, and risk-adjusted capitated contracts with Massachusetts Medicaid and Medicare, Commonwealth Care Alliance has improved health outcomes and reduced hospital inpatient admissions and emergency department visits.

Learn the business side of health care to guide more comprehensive programs

“I initially tried to dive right in to do the right thing for the patient . . .  but soon realized if you’re going to try to change the health care system, you have to understand it from the system and payment side,” says Corey Waller, MD, medical director, Spectrum Health’s Center for Integrative Medicine. To get the leadership buy-in and support necessary for rethinking care for complex patients, providers need to be able to speak the same language as health plan/system executives and CFOs, who may not be clinicians. By understanding the ways that health and payment systems work, providers may be better equipped to offer solutions that make sense to the financial decision-makers while also addressing the issues facing patients.

Continue to care for patients to keeps things in perspective

“To develop and run programs effectively, you have to actually feel the day-to-day joy and the pain of those programs,” says John Loughnane, MD, senior vice president medical services and chief medical officer, Commonwealth Care Alliance. Physicians taking on administrative leadership roles should ideally continue to care for patients because it allows them to keep patient needs at the forefront of their systems-level work. Additionally, to avoid burnout, providers need to have some “wins” and clinical care can often provide that satisfaction more quickly than administrative processes.

These recommendations all have one thing in common: providing care to high-need, high-cost individuals requires constant personal and organizational evolution. In the future, look for more practical strategies from the Innovation Lab to help providers at the frontlines design more effective approaches to care for those with complex needs.

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