Online 'Playbook' for High-Need Patients Released

Ken Terry

December 09, 2016

A new online "playbook," designed to improve the care provided to patients with complex needs, including medical, behavioral, and social issues, was launched today at the inaugural meeting of the National Center for Complex Health and Social Needs. This new organization is led by Jeffrey Brenner, MD, who is nationally recognized for his work with high-need patients in Camden, New Jersey.

Five foundations — the John A. Hartford Foundation, the Peterson Center on Healthcare, the Robert Wood Johnson Foundation, the SCAN Foundation, and the Commonwealth Fund — sponsored the playbook and will also participate in its further development and dissemination.

Developed by experts at the Institute for Healthcare Improvement "The Playbook: Better Care for People With Complex Needs" is described as a resource to help health system leaders and insurers improve care for patients with complex medical and social issues. It offers insights about high-need patients, examples of successful approaches to care, guidance on making the business case for these models, and opportunities for policy and payment reform.

According to a news release, "The foundation leaders believe that with better access to care that coordinates patients' medical, behavioral, and social needs — along with improved provider-patient communications — patients with high needs will be less likely to delay care or seek emergency care for nonurgent issues."

Overcoming Barriers

Melinda Abrams, vice president of delivery system reform at the Commonwealth Fund, told Medscape Medical News that a key strategy of the foundations is to use the playbook to identify and explain models "that show a lot of promise and have a lot of evidence behind them."

In addition, she said, the foundations will work together to better understand the barriers to these models and how to overcome them. One such barrier, she noted, is the fee-for-service payment model, which discourages physicians from providing nonvisit care.

"Most of the promising models for high-need patients were able to flourish and be sustained when they were in a value-based payment model," Abrams said, referring to risk contracts that incentivize providers to lower costs. "So the care model depends on new financial incentive structures and more flexibility for providers to be creative in how they blend physical health services, behavioral health services, personal care for people at home, and meeting some of their nonmedical needs."

Among the organizations that have been able to help patients with complex needs, she said, are Boston's Commonwealth Care Alliance, which serves elderly and disabled people; CareMore, a California-based Medicare Advantage plan, which covers home visits by doctors and social workers to assess and address the needs of complex patients; and Montefiore Medical Center in Bronx, New York, which also uses social workers and has relationships with local housing agencies.

High-Need Survey

Along with the playbook announcement, the foundations presented the results of a Commonwealth Fund survey showing that patients with complex problems tend to lack good access to care and experience more social and economic challenges than other people do.

"The results suggest that the health care system is largely failing to meet the complex needs of these patients," stated the report from the Commonwealth Fund.

The survey got responses from 3009 adults, including 1805 high-need adults and 1204 adults who didn't have high needs. Compared with the general population, the study found, the high-need population was older, less educated, and poorer. Many high-need patients reported social isolation, were stressed, or were worried about material hardships.

Nearly half of these patients had been hospitalized or had gone to the emergency department in the previous 2 years. Forty-four percent of them had delayed care in the past year because of an access problem, such as lack of transportation, limited office hours, or an inability to get an office appointment quickly.

To Abrams, this finding indicates a need for more flexible payment models and care teams. Providers require more flexibility to deal with the full range of patient needs, including working with community organizations to address social and behavioral health needs, she said.

Most high-need patients had a regular doctor or place of care, the survey found. But just two thirds of them could get a medical question answered the same day they asked it. And only 35% of high-need patients could obtain medical care in physician offices after hours, compared with 53% of other adults.

Fifty-seven percent of high-need patients had difficulty with activities of daily living. Just 38% of those patients had anyone to help them at home. In most cases, they received that support from family members.

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