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.