Start: July 2016
End: December 2018
Funder: Robert Wood Johnson Foundation
Patients with complex needs are a relatively small group of individuals who account for a disproportionate amount of health care costs. These individuals frequently have multiple medical, mental health, and substance use treatment needs, and may also face social and economic challenges that complicate their health outcomes. As innovative efforts across the nation uncover effective ways to organize, deliver, and pay for care for this population, there is increasing interest in developing models that can be readily scaled and replicated.
Transforming Complex Care was a multi-site demonstration aimed at refining and spreading effective care models that addressed the complex medical and social needs of high-need, high-cost patients. Made possible with support from the Robert Wood Johnson Foundation, and in line with its vision of building a culture of health for all Americans, this national initiative included six organizations that were enhancing existing complex care programs within a diverse range of delivery system, payment, and geographic environments. The sites and the regions they served were:
- AccessHealth Spartanburg, Spartanburg County, South Carolina
- Mountain-Pacific Quality Health, State of Montana
- OneCare Vermont, State of Vermont
- Redwood Community Health Coalition, Northern California
- ThedaCare, Eastern Wisconsin
- VCU Health System, Central Virginia
Over two years, the sites refined targeted strategies across six key domains for improving complex care, including: (1) care model enhancements (2) data and analytics; (3) workforce development; (4) financing and accountability; (5) governance and operations; and (6) policy and advocacy. The sites built on their existing programs, guided by input from their peers in a learning collaborative and with technical assistance from CHCS and other experts in the field.
Related Resources
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ReportOrganizing Complex Care for Rural Populations: A Case Study of Three Montana Communities March 2019
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ReportAlternative Staffing Models to Improve Care for Complex Patients in their Homes and Other Settings: Early Findings from the Transforming Complex Care Initiative March 2019
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BriefOpportunities for Complex Care Programs to Address the Social Determinants of Health February 2019
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Profile SeriesNew Faces of the Complex Care Workforce: Reflecting and Connecting with Patients
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WebinarApproaches to Extending Complex Care Models into the Community: Emerging Evidence August 2018
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ProfileAccessHealth Spartanburg: Wrap-Around Community Support for South Carolina’s Most Vulnerable Patients May 2018
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ProfileThedaCare: Leveraging Community Paramedics to Bridge Persistent Gaps in Care May 2018
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BriefScreening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations October 2017
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ProfileVirginia Commonwealth University Health System: Beyond the Walls and Into Communities October 2017
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ProfileMountain-Pacific Quality Health Pilot: Closing the Gaps in Rural Complex Care October 2017
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WebinarIntegrating Community Pharmacists into Complex Care Management Programs June 2017
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WebinarCommunity Paramedicine: A New Approach to Serving Complex Populations May 2017
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Technical Assistance BriefIntegrating Community Health Workers into Complex Care Teams: Key Considerations May 2017
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WebinarUsing Community Health Workers and Volunteers to Reach Complex Needs Populations April 2017
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ReportOpportunities to Improve Models of Care for People with Complex Needs November 2015