Coming into our Complex Care Innovation Lab meeting last month, we knew full well that the Medicaid health care delivery system is transforming itself — sometimes at breakneck speed — in recognition of the fact that health status is not all about medical care. On average, it accounts for less than 20 percent of our “healthiness.” For the individuals in Medicaid with complex physical, behavioral, and social needs, medical care by itself is probably responsible for substantially less. The social determinants of health ring loudest for people beset by poverty, food deserts, unsafe streets, poor housing, and potential involvement with the criminal justice system.

As the message about the Culture of Health for all Americans — including those with complex needs — continues to spread, the need to go beyond the traditional medical model and address the social determinants of health is crystal clear. Less clear yet is how to get there, particularly for individuals with complex needs. Last year CHCS conducted a national scan to help frame the key domains for improving complex care. At our recent meeting with leading innovators in complex care from across the country, who are grappling with these issues on the ground, we identified major emerging opportunities within these domains:

1. Promoting accountable financing approaches that drive integration

Examples of accountable integrated care for high-need, high-cost populations include: downside risk-bearing accountable care organizations; regional, fully capitated health plans; and fully integrated models for those dually eligible for Medicare and Medicaid; etc.

2. Linking (and listening) to the community

Medicaid managed care organizations and health systems need to establish formal linkages with the community-based organizations (CBOs) that deliver social services. In fact, they need to think about creating CBO networks just like they build primary care provider networks. By doing so, they can better respond to on-the-ground health-related concerns (e.g., access, safety, cultural competence, etc.) of particular neighborhoods.

3. Using data to inform and evaluate the approach

To maximize the effectiveness of complex care programs, we need to fine-tune our use of health and social services data for identifying high-need members early and, after getting them into care, for determining when to “graduate” them to less intensive levels of service. At the same time, existing evaluation strategies for complex care programs need to go beyond cost and utilization outcomes to include overall wellness and community-level impacts.

4. Identifying key care model design principles to support scale and spread

While it is clear that a “one size fits all” approach to working with complex populations is unfeasible, several key principles for designing successful models are emerging through the work of organizations such as those in the Innovation Lab and others. These include the use of an alternative workforce that supports peer and community health worker roles; implementing a trauma-informed approach to care; and team-based care, to name a few. Identifying these core model elements will be critical to building and scaling successful programs in a variety of settings.

5. Working upstream to prevent complexity before it starts

The downstream care and cost issues confronting the health care system — as well as other social systems, such as housing and criminal justice — are the predictable consequences of failures to intervene upstream, including during the first 1,000 days of life to prevent adverse childhood events. We are otherwise launching many children onto socially constructed pathways to super utilization.

Even the nation’s leading innovators in complex care for low-income people, such as those in the Innovation Lab, recognize that we are nowhere near knowing all that we need to know to intervene effectively with these populations. We do not have all the data we need to predict which beneficiaries will benefit the most from which evidence-based practices or the metrics to substantiate our assumptions. We do not know how to design and use alternative payment models to promote the right interventions by health care systems and their social services partners.

There is so much to be done. By beginning to address these challenges through the Complex Care Innovation Lab, made possible through Kaiser Permanente Community Benefit, it feels like we are making genuine headway in a number of these areas. We intend to share our insights in a series of upcoming blogs and other publications addressing:

  1. Policy approaches to advance complex care strategies;
  2. Cross-sector collaboration and community engagement;
  3. Data and evaluation;
  4. Core principles of care model design; and
  5. Upstream opportunities.

We hope you will stay tuned as we do so.

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