November 13, 2018 | Newsletter

Every day, health care providers and systems across the nation are testing models to improve care for people struggling with a complex combination of medical, social, and behavioral health needs. Key steps in developing effective complex care management programs include finding ways to consistently identify patients, screen and address for social determinants of health, develop tools to coordinate care across settings, and maximize scarce community resources.

The following resources and profiles represent a sampling of the innovative work going on behind the scenes within complex care, and draw on themes developed through Transforming Complex Care, an initiative led by the Center for Health Care Strategies and supported by the Robert Wood Johnson Foundation.

Inclusion and Exclusion Criteria for Complex Care Programs: Survey of Approaches

This technical assistance tool, which summarizes approaches from 10 complex care programs across the country, provides organizations looking to refine or start initiatives for individual with complex needs with examples of eligibility and graduation criteria from innovators in the field.

Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations

This brief examines how complex care programs are addressing social determinants of health (SDOH) for populations with complex needs. It reviews key considerations for organizations seeking to use SDOH data to improve patient care, including implementing assessment tools, collecting patient-level information, creating workflows to track and address patient needs; and identifying community resources and tracking referrals.

Approaches to Extending Complex Care Models into the Community: Emerging Evidence

This webinar — featuring speakers from ThedaCare Health System and Virginia Commonwealth University Health System — focused on building effective care models that address social determinants of health, developing tools that support community-based care team members, and designing a business case for sustaining complex care models.

Addressing Social Determinants of Health: Connecting People with Complex Needs to Community Resources

During this webinar, speakers from AccessHealth Spartanburg and Petaluma Health Center shared strategies for addressing SDOH through screening approaches, innovative technologies that track social service referrals, and development of strong connections with community partners.

Complex Care Innovation in Action

These profiles highlight promising approaches that complex care programs are using to better identify and address patients’ unmet needs:

Find more resources on improving care for individuals with complex medical, social, and behavioral health needs at