While uncertainty and debate about health care reform remains, there is near-universal agreement on the need to improve care delivery and health outcomes and decrease the rate at which spending continues to grow. An underrecognized but crucial component to achieving these goals is redesigning care for “high-need patients”—in other words, the small cohort of patients with complex needs who represent the greatest usage of the health care system.

Currently, 1 percent of patients account for more than 20 percent of health care expenditures, and 5 percent account for nearly half of the nation’s spending on health care, according to the Agency for Healthcare Research and Quality. Driving these costs for high-need patients are the functional limitations that impact patients’ daily living and ability to cope with health challenges, leading to their use of health care and social services that are often too late and poorly matched to their needs.

A 2014 survey conducted by the Commonwealth Fund found that high-need patients are highly susceptible to lack of coordination within the health care system and are more likely to experience cost-related barriers to accessing care, compared to other older adults. A 2016 Commonwealth Fund survey found that nearly two-thirds of high-need patients reported hardships with housing, meals, or utilities and that this population was also more likely to report feeling socially isolated, compared with the general adult population. Providing quality care for these high-need patients is a sizable challenge—yet it’s also an area where strategic attention and investment could yield significant payoffs for patients and the entire health system.

Indeed, a number of health systems have designed successful models that leverage an understanding of the unique characteristics of high-need patients to deliver quality care at sustainable costs.

Although there is no one-size-fits-all solution, a new publication from the National Academy of Medicine (NAM) says successful models generally share a number of common features across four dimensions:

    • Focus of service setting. Successful models tailor their care settings for either a targeted age group with various combinations of illnesses or individuals who use a significant amount of care. Examples of care settings include enhanced primary care, transitional care, integrated care, home-based care, and others.
    • Care and condition attributes. Successful models include practices such as targeting patients most likely to benefit from an intervention, coordinating care and communication among patients and providers, promoting patient and family engagement in self-care, and facilitating transitions from the hospital and referrals to community resources.
    • Delivery features. Successful models often feature the use of care managers alongside primary care providers to identify and work with high-risk patients. In addition, they often put high-risk patients under the care of specific physicians who treat a limited number of patients to enhance communication and adherence.
    • Organizational culture. For care models to be successful, organizations must emphasize leadership at all levels; be capable of adapting based on the size of the program and local circumstances; offer specialized, customizable training for team members; and effectively use data access, sources, and application.

Denver Health: A Real-World Example

In 2012, Denver Health—an integrated system that includes an acute care hospital, all of Denver’s federally qualified health centers, a public health department, an emergency 9-1-1 call center, a health maintenance organization, and several school-based health centers—set out to create a new care model and transform its primary care delivery system by providing individualized care that would more effectively meet medical, behavioral, and social needs for its largely low-income population. In designing its 21st Century Care model, which included modifications to better serve its high-need patients, Denver Health’s goals were to improve the experience of care, improve the health of populations, and reduce per capita costs of health care. Early in its implementation, a fourth goal also emerged: improving provider engagement and creating healthier and happier patients.

With support from a Center for Medicare and Medicaid Innovation award, Denver Health was able to redesign its health teams and invest in health information technology to enable population segmentation and categorization of patients by clinical risk groups. Funds were also spent on rapid evaluation efforts to refine the care model’s design.

The new model matched care delivery to four risk tiers. Healthy individuals were assigned to tier one and interacted with staff using Denver Health’s eTouch text messaging platform. Individuals in tier two received additional chronic disease management, such as lay patient navigators, nurse care coordination and home visits, and environmental scans for children with asthma. For patients in tiers three and four, integrated behavioral health assessments and care were standard, as was the inclusion of nurse care coordinators, clinical pharmacists, and clinical social workers as part of the care team. For patients in tier four, Denver Health relied on specialized intensive outpatient clinics to serve as adult patients’ medical homes or multidisciplinary special needs clinics for high-risk pediatric patients. Targeted toward individuals who had experienced multiple potentially avoidable inpatient admissions within one year, care teams in these clinics included a dedicated social worker and navigator, and teams were responsible for a limited number of patients. This clinic also worked closely with the Mental Health Center of Denver.

Denver Health’s systems modification paid off, particularly for high-need patients. These innovations not only improved patient outcomes and patient and provider satisfaction, but also resulted in reductions in expected spending. Over a one-year period, the system saw an approximately 2 percent reduction in expected spending. Most of the savings were driven by a decrease in hospitalizations among patients in tier four. Denver Health’s success demonstrates the real potential of strategic models to improve care for these patients while curbing health care spending.

The Opportunity

Health systems can play an essential role in improving care for our nation’s high-need patients. That’s why we, as members of an initiative under the NAM Leadership Consortium for a Value and Science-Driven Health System, are spreading the word about the characteristics of high-need patients, the challenges they face, and the features of successful care models for this population. This initiative was conducted in partnership with the Harvard T.H. Chan School of Public Health, the Bipartisan Policy Center, the Commonwealth Fund, and publication sponsor, the Peterson Center on Healthcare.

To promote improvements to the care of high-need patients, health systems should work with payers, providers, and other health systems to better identify and target high-need patients, test new practices and tools, and develop interactive electronic health records that can include functional and behavioral status and social needs. They should use established metrics and quality improvement approaches to continuously assess and improve care models and partner with community organizations, patients, caregivers, and social and behavioral health service providers outside the health care system to create patient-centered care plans. Health systems can also assess their current culture and promote changes needed to build new and successful care models, blending medical, social, and behavioral approaches.

Of course, health systems can’t do this alone. At the federal level, policy makers should improve coordination among the Medicare and Medicaid programs to increase access to needed services and reduce the burden on patients and caregivers, and should continue payment policy reforms that align initiatives to incentivize pay-for-performance instead of fee-for-service models. Policy makers should also explore the expansion of programs that could mitigate the financial strain of caregiving, such as Medicaid’s Cash and Counseling—a national program in which the government gave people cash allowances to pay for the services and goods they felt would best meet their personal care needs and counseling about managing their services—and incentivize the adoption and use of interoperable electronic health records that include functional, behavioral health, and social factors.

Payers can develop financing models to provide social and behavioral health services that will both improve care and lower the total cost of care for high-need patients, recognizing that even cost-neutral programs are worth supporting if the outcome is positive for patients. Providers can learn to work collaboratively in teams and engage with patients, care partners, and their caregivers in the design and delivery of care.

Return on investment for most models of care for high-need patients will take time. But one of the most expensive and challenging populations for the current health care system will remain underserved and continue to drive health care spending until there is a unified effort to improve their care. We know there are models that work. Now, action is critical, and while health care reform remains on center stage in the national policy agenda, the time is right. By taking the lead in the bold changes needed for this transformation, health systems can play a pivotal role alongside all stakeholders in reducing costs and improving the health of some of the nation’s most vulnerable patients.