PioneersTCC-Kickoff_3 in improving care for high-need, high-cost populations are breaking ground across the country. While best practices for enhancing complex care are becoming clear, many emerging models are unique to local contexts and need to be adapted for use elsewhere. To help the next wave of leaders capitalize on the work of early innovators, the Robert Wood Johnson Foundation has funded Transforming Complex Care to spread successful complex care innovations to other communities across the United States.

Under this national multi-site demonstration, the Center for Health Care Strategies is working with six organizations in a diverse range of delivery system, payment, and geographic environments to refine their complex care approaches. The sites will pursue strategies across key domains for improving complex care: care model enhancements; data and analytics; workforce development; financing and accountability; governance and operations; and policy and advocacy. Examples of the sites’ strategies include:

Standardizing care management approaches

Standardizing successful care management processes is a crucial element of high-quality complex care. Redwood Community Health Coalition, a network of 17 health centers in Northern California, is identifying effective care management strategies among its members. Over time, the best practices will be instituted across its network. OneCare Vermont is developing a care management and event notification system to deliver team-based, patient-centered care more efficiently. The system will facilitate communication among patients, family members, and providers to improve patient engagement and self-management and ensure that providers receive up-to-the-minute information. 

Using “outside-the-box” data sources to target interventions for those in need

Innovative providers are integrating hybrid data sources—including claims, information about patients’ social needs, and provider and patient perspectives—to identify patients who can benefit the most from complex care interventions. VCU Health System (VCU) is combining utilization and cost data with a geospatial analysis of patient zip codes and neighborhood risk factors to pinpoint where community-level interventions are needed most. This “hot and cold spotting” approach will help VCU target its interventions. VCU is also incorporating patient input, notes on unmet social needs, and consumer activation (also known as engagement) scores into electronic health records to facilitate care planning.

Extending health care reach through technology and workforce innovation

In rural areas where the nearest provider might be hundreds of miles away, it is often difficult for patients to establish relationships with providers and get the care they need. Mountain-Pacific Quality Health Foundation is connecting patients and providers by pairing traditional home visits with video chat technology. Outreach workers making home visits will link patients and remote providers through video chats to help coordinate the full range of care, including addressing social needs. In Wisconsin, ThedaCare is engaging paramedics to link patients with local primary care providers to support more appropriate use of emergency care. AccessHealth Spartanburg and VCU are both testing the use of community health workers to connect patients with social supports that can improve health outcomes.

Leveraging alternative financing approaches to enhance complex care

An array of alternative financing strategies have emerged to transform the way that providers are reimbursed for the delivery of high-quality care. For example, Redwood Community Health Coalition is working with Partnership Health Plan, a California Medicaid managed care organization, to implement Section 2703 of the Affordable Care Act to develop health home services for Medicaid beneficiaries with chronic conditions. The Coalition will also create alternatives to its current fee-for-service model. 

Next steps in refining and scaling complex care models

These examples offer a glimpse into the innovative ways that Transforming Complex Care sites are seeking to advance complex care. Sites are building coalitions and driving mutual goals by partnering with community-based organizations, patient advisory groups, and government agencies, among others. As sites adapt best practices to their particular contexts, insights from the organizations’ efforts will be shared nationally to serve as catalysts for reducing costs, improving outcomes, and enhancing quality of life for those who need it the most.

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