WIHI: When Everyone Knows Your Name: Identifying Patients with Complex Needs

Date: January 29, 2015


  • Catherine Craig, MPA, MSW, Independent Consultant; Faculty, Better Health and Lower Costs for Patients with Complex Needs, IHI
  • Matt Stiefel, MPA, MS, Senior Director, Center for Population Health Care Management Institute, Kaiser Permanente
  • Eleni Carr, MBA, MSW, Senior Director of Care Integration, Cambridge Health Alliance
  • Kathy Weiner, MHSA, Regional Executive Director, Medicare, Kaiser Permanente

 A relatively small percentage of the US population accounts for the largest share of health care costs. Everyone knows who we're talking about, right? Well, not exactly. Broad assumptions (e.g., high utilizers of the emergency department) and sweeping generalizations often substitute for more robust inquiries and analysis designed to better pinpoint a hospital or clinic's patients with unmanaged, complex health problems. And, without this specificity, it's hard to know who will benefit most from additional supports and interventions.

This is among the reasons why an IHI Collaborative involving some 45 health care organizations has been focusing like a laser this past year on developing reliable ways to identify patients with complex needs. It's hard but necessary work, and we explored just what that hard work entails on this WIHI.


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