Funder: Robert Wood Johnson Foundation

Author: Derek DeLia, MedStar Health Research Institute and Jolene Chou, Rutgers Center for State Health Policy

March 2019 |


Through the Transforming Complex Care initiative, a national initiative led by the Center for Health Care Strategies with support from the Robert Wood Johnson Foundation, six complex care programs were tasked with refining and spreading effective care models that addressed the complex medical and social needs of high-need, high-cost patients.

This study analyzes three of the participating complex care programs — Access Health Spartanburg in South Carolina, VCU Health in Virginia, and Thedacare in Wisconsin — that use non-traditional workforce strategies to extend the reach of their clinics to better engage complex patients in their homes, at medical appointments, and other community locations. The researchers interviewed key members of each complex care team supplemented with available quantitative data collected by the sites. While not sufficient for rigorous program evaluation, the quantitative data provide early indications of how these programs may have influenced various medical and social indicators.

Key considerations include the breadth of patient enrollment criteria, comprehensiveness of clinical and social support services, flow of information between home care and clinic care, and approaches to facilitating trust between patients and home-visit staff. These considerations must be made in the context of local patient needs, health system resources, and emerging health policy reforms. The paper also includes a discussion of how the experiences from the three sites can be used by providers and health systems considering the use of alternative staffing models to improve care for complex patients.