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 brought together leading national innovators in improving care for this high-need, high-cost population. Working together, these national leaders sought 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 participated in the final Innovation Lab cohort. 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

Additional Innovation Lab activities 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.

Through in-person meetings, peer-to-peer exchanges, pilots and analyses, participants examined persistent challenges for 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 were 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 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.