A new 'playbook' for improve care for high-need patients

Best practice website offers a range of resources

The Commonwealth Fund recently released a survey detailing the challenges high-need patients face navigating the health care system—as well as a "playbook" website with resources for improving their care.

The survey was conducted between June 22 and Sept. 14 and included 3,009 respondents. Overall, 1,805 of the respondents were classified as high-need patients based on factors such as their number of chronic conditions, age, and insurance status.

According to the survey, high-need patients are generally older, have lower levels of education and income, are disproportionally female, and are disproportionately African-American.

Access challenges

Nearly half of high-need patients who responded to the survey said they had been hospitalized overnight or had sought care at an ED multiple times in the past two years. And 19 percent said they used the ED for medical issues that could have been addressed in a clinic or a physician's office.

Overall, the survey found that the majority of high-need patients (95 percent) have consistent access to health care, but they lack access to the coordinated medical, behavioral, and social services necessary to avoid costly visits to the hospital.

High-need respondents reported particular difficulty in gaining access to care coordinators, aid in managing functional limitations, emotional counseling, and transportation services. Specifically, the survey found that:

  • 57 percent of high-need patients reported difficulty completing daily activities, and only 38 percent said they usually or always had assistance;
  • 53 percent used multiple heath care services or saw multiple doctors in the past year—but only 43 percent of those patients had an active, "informed" care coordinator;
  • About 50 percent reported experiencing emotional distress, but only 39 percent were able to access counseling as promptly as they desired; and
  • 44 percent said they encountered delays accessing care over the past year because of lack of transportation, limited office hours, or difficulty getting timely appointments.


In an issue brief that accompanied the survey, the Commonwealth Fund highlighted three implications of the survey findings.

1. Providers should understand patients' social and behavioral needs in addition their medical needs. According to the brief, improving high-need patient outcomes requires that payers, providers, and other stakeholders think creatively about how to address the non-medical factors that influence health. "Health care providers should … collaborate with social service agencies, community-based organizations, and behavioral health providers to deliver better outcomes and avoid high-cost care," the brief suggests.

2. Provide additional support for high-need patients. The issue brief recommends that health care providers invest in care coordinators, transportation services, and resources designed to help patients managing functional limitations, as well as other services to facilitate care access.

3. Improving high-need patient care can improve outcomes while potentially lowering costs. According to the brief, "increasing patient-centered communication and enabling easier access to appropriate care and

information" are the most promising ways to improving high-need patient care. In turn, the brief concludes that "increasing the health care system's responsiveness to patients in this way could help avoid unnecessary care that drives up the nation's health care costs."

A 'playbook' for improving care

In conjunction with the survey, the Commonwealth Fund, John A. Hartford Foundation, Peterson Center on Healthcare, Robert Wood Johnson Foundation, and SCAN Foundation launched a new website in partnership with the Institute for Healthcare Improvement called "The Playbook: Better Care for People with Complex Needs."

The groups billed the website as a "first-of-its-kind hub" that aims to pull together experts and stakeholders to address complex care. The website contains resources for health system leaders, policy makers, and payers, and it will be updated over time.

Resources available on the website cover a wide variety of topics, including:

  • Developing intensive outpatient care programs;
  • Improving care for individuals who are dually eligible for Medicare and Medicaid; and
  • Developing care management programs for high-need patients.

In addition, the website includes case studies, guidance on making the business case for new care models, and briefs on policy and payment reform options.

According to Melinda Abrams, VP of delivery system reform at the Commonwealth Fund, the strategies disused on the playbook website are evidenced-based and typically require alternative payment models. "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 explained. "So the care model depends on new financial incentive structures and more flexibility for providers to be creative in how they blend" different types of services (Finnegan, Fierce Healthcare, 12/9; Ross, "On Call," STAT News, 12/9; The Playbook, accessed 12/12;  Terry, Medscape, 12/9; Commonwealth Fund brief, accessed 12/12; Commonwealth Fund release, 12/9).

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