Individuals with complex health and social needs account for disproportionate health care costs throughout the US health care system. These individuals typically have multiple chronic physical and behavioral health conditions and often face significant economic and social barriers to achieving better health, including financial insecurity, unstable housing, exposure to trauma, and social isolation. Innovative health care organizations across the country are testing new ways to more effectively meet the needs of these vulnerable patients and reduce unnecessary care costs.

CHCS’ Complex Care Innovation in Action series spotlights pioneering health care organizations within a diverse range of delivery system, payment, and geographic environments that are enhancing care for individuals with complex needs. Future profiles will introduce promising models of care emerging in communities across the US. Learn more at the links below:

Southwestern Pennsylvania: Peers Help People with Substance Use Disorders Move Toward Recovery – This profile explores how Allegheny County, Pennsylvania is successfully using people in recovery to build rapport and coordinate outpatient treatment for individuals identified with substance use disorders in the emergency department or upon inpatient admission. (July 2018)

AccessHealth Spartanburg: Wrap-Around Community Support for South Carolina’s Most Vulnerable Patients – This profile focuses on AccessHealth’s community case managers, who connect Spartanburg County’s uninsured, adult population to primary care providers and community services. (May 2018)

ThedaCare: Leveraging Community Paramedics to Bridge Persistent Gaps in Care – This profile features ThedaCare’s community paramedicine program, which deploys paramedics to the homes of patients with complex needs to review medications, address social needs, and support patient self-management. (May 2018)

Mountain-Pacific Quality Health Pilot: Closing the Gaps in Rural Complex Care – This profile focuses on Mountain-Pacific’s ReSource Team, which pairs community health workers and volunteers with technology to connect patients in hard-to-reach rural or frontier areas to health care and social services. (October 2017)

Virginia Commonwealth University Health System: Beyond the Walls and Into Communities – This profile examines VCU Health’s TakeCCARE program, which uses “hotspotting” and “coldspotting” techniques to identify high-opportunity neighborhoods where outreach workers can help individuals with complex health and social needs.(October 2017)

See also Bridging Community-Based Human Services and Health Care: Case Study Series