Start: May 2013
Funder: Kaiser Permanente Community Health and Robert Wood Johnson Foundation
Individuals with complex needs — sometimes referred to as “high-need, high-cost” patients — typically have multiple physical and/or behavioral health conditions, as well as significant social needs. These patients face many challenges to accessing quality health care, including a fragmented system, lack of supports, and misaligned payment structures, which often lead to poorer health outcomes and higher costs. Addressing the social determinants of health is at the center of improving outcomes for this population.
How CHCS is Helping to Advance Complex Care
The Complex Care Innovation Lab, supported by Kaiser Permanente Community Health and the Robert Wood Johnson Foundation, is an initiative of the Center for Health Care Strategies that brings together leading national innovators in improving care for this high-need, high-cost population. Working together, these national leaders are seeking to:
- Advance emerging opportunities to improve outcomes for low-income individuals with complex health and social needs;
- Contribute to the evidence base regarding how to successfully build, operate, and evaluate complex care programs; and
- Serve as a leading source of policy recommendations to sustain effective models and spur new approaches, particularly related to broader health care payment and delivery system reforms.
The following organizations are currently participating in the Innovation Lab. For more details about participants, download the Innovation Lab overview.
- Boston Health Care for the Homeless Program, Massachusetts
- Camden Coalition of Healthcare Providers, New Jersey
- CareOregon, Oregon
- Center for Health Care Services, Texas
- Commonwealth Care Alliance, Massachusetts
- Community Care of North Carolina, North Carolina
- Denver Health, Colorado
- Hennepin Health, Minnesota
- Johns Hopkins Community Health Partnership, Maryland
- Los Angeles County Department of Health Services, California
- Maimonides Medical Center, New York
- Southcentral Foundation, Alaska
- University of California, San Francisco
Current Innovation Lab activities are focused on:
- Developing insights into how to identify and effectively interrupt the trajectory of “rising risk” populations and prevent future high utilization; and
- With funding from the Robert Wood Johnson Foundation, CHCS is coordinating the Community Partnership Pilot to identify key insights and best practices for building effective partnerships between health care systems and the community.
Other Innovation Lab areas of focus include: (1) core model principles; (2) cross-sector collaboration; (3) data and evaluation; and (4) policy and financing. Through in-person meetings, peer-to-peer exchanges, pilots and analyses, participants are examining persistent challenges for each of these issues; identifying tools, concepts, and perspectives from multiple sectors; and developing new approaches for improving care for populations with complex needs. Lessons from the Innovation Lab are shared broadly to inform best practices and encourage further innovations in the field of complex care.
The creation of the Innovation Lab stemmed from CHCS’ earlier Kaiser Permanente-funded work in the Medicaid Value Program and the Rethinking Care Program, both national initiatives that sought to identify innovative models of care delivery for Medicaid recipients with complex needs. The Innovation Lab has also spurred the creation of additional CHCS programs to accelerate promising practices in the field of complex care, including Advancing Trauma-Informed Care, Transforming Complex Care, the Medicaid Early Childhood Innovation Lab, and Community Management of Medication Complexity Innovation Lab, among others.
Technical Assistance ToolGeographic Data Sources for Assessing Health-Related Social Risk Factors August 2020
WebinarBeyond Cost and Utilization: Rethinking Evaluation Strategies for Complex Care Programs April 2018
BriefCross-Sector Service Use and Costs among Medicaid Expansion Enrollees in Minnesota’s Hennepin County October 2017
WebinarIntegrating Community Pharmacists into Complex Care Management Programs June 2017
WebinarCommunity Paramedicine: A New Approach to Serving Complex Populations May 2017
Technical Assistance BriefIntegrating Community Health Workers into Complex Care Teams: Key Considerations May 2017
Journal ArticleA Collective National Approach to Fostering Innovation in Complex Care May 2017
WebinarUsing Community Health Workers and Volunteers to Reach Complex Needs Populations April 2017
BriefComplex Care Program Development: A New Framework for Design and Evaluation March 2017
BriefUsing a Cost and Utilization Lens to Evaluate Programs Serving Complex Populations: Benefits and Limitations March 2017
Technical Assistance ToolCaring for Patients with Complex Needs: Exploring Emerging Innovations March 2017
BriefDisruptive Innovation in Medicaid Non-Emergency Transportation February 2017
Technical Assistance BriefTraining Staff in Trauma Treatments: Considerations for Complex Care Providers February 2017
CompendiumEvaluating Complex Care Programs Series
BriefThe Business Case for Community Paramedicine: Lessons from Commonwealth Care Alliance’s Pilot Program December 2016
Technical Assistance ToolCommunity Paramedicine Business Case Assessment Tool December 2016
Interactive MapPrograms Focusing on High-Need, High-Cost Populations August 2018
BriefTrauma-Informed Care: Opportunities for High-Need, High-Cost Medicaid Populations March 2015
BriefDigital Health Innovations for Medicaid Super-Utilizers: Consumer Feedback December 2013
BriefStrategies to Reduce Costs and Improve Care for High-Utilizing Medicaid Patients: Reflections on Pioneering Programs October 2013