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Easier Said Than Done: Improving Health for People with Complex Needs

By John Gauthier | Friday, June 27, 2014

“Learning about people's strengths, values, needs, and challenges is the foundation for redesigning care,” says Catherine Craig, MPA, MSW, faculty for the IHI Better Health and Lower Costs for Patients with Complex Needs Collaborative. Her expertise includes fostering collaboration with disenfranchised groups, and navigating the intersections between policy areas and organizations by identifying and translating common priorities.


July is going to be an exciting month at IHI as we begin working with teams in the Better Health and Lower Costs for Patients with Complex Needs Collaborative. The Collaborative will help participating teams manage services for the population of people, usually living with multiple health and social challenges, who are caught in patterns of very high-cost health care utilization and still not enjoying good health outcomes.

Team participating in the Collaborative will follow a step-wise method to improve health outcomes and patient experience while driving down cost, including:

  • Identify a particular high-risk population that will be the focus of their work;
  • Assess the assets and needs of this population by learning from patients’ experiences;
  • Co-create and execute new care designs to test for impact and cost savings; and
  • Increase the scale and reach of successful care designs in fivefold to tenfold jumps.

This Collaborative grows out of years of work within the IHI Triple Aim Improvement Community, where we have seen over and over again the enormous value of meeting one-on-one with people in the target population to listen to their stories. Certainly, one-to-one work happens all the time in the medical setting, but these new conversations are not focused on finding solutions to the person's up-to-the-minute needs. Rather, helping professionals are pulling up a chair to ask questions designed to get the person talking, and keep them talking.

When we use a simple question, like this one taken from the HARMS-8, developed by CareOregon — "What do you think causes your condition to get so bad you need to be in the hospital?" — teams often report that they learn entirely new information that they had never uncovered before. They may learn about a bus route that has gone out of service, leaving the person with no known way to get to appointments with the treating physician, or about a child's health care appointments that conflict with those of a devoted parent, but the parent has kept the child’s appointments in lieu of their own.

Often, it is a series of logistical challenges and health system complexities that have piled up to form a sizable obstacle between the person and their health-sustaining behaviors and preventive care. When we learn about these obstacles that were previously hidden from view, ideas spark to mind about possible solutions, often springing right from the patient, who has considered the challenge for a long time. Plan-Do-Study-Act cycles can literally suggest themselves when we uncover obstacles that people face, and these conversations are a clear and elegant way that people using the care system are instrumental in redesigning it.

The most exciting aspect of the deep-listening role of the helping professional in these conversations is the transformational power it has. When the person at the center of the care plan outlines their own set of obstacles to good health and consistent care, we learn their values, their strengths, and the huge array of skills they rely on day-to-day. As often as possible, the meeting is in the person's own home, lending a world of understanding to the helper.

When I was a young case manager in an alternative high school program working with teenage parents, I made a visit to a teen mom in the apartment she shared with her mother. We stood in her room, furnished with her son's safe crib and my student's mattress on the floor, and my eyes were drawn to the only decoration on the walls: a Certificate of Achievement that our department had created to award students with good progress each month. I remembered the skepticism our team had had, wondering if the ink-bordered photocopies would hold any value for our students. And in that moment, I realized that this young student was nourished by her own accomplishments, and that she saw herself as someone who achieves.

I brought this profound knowledge back to my colleagues, and we were energized to try out new small changes that may help our students find hope for themselves and propel them on their journey to graduation and beyond. This is the heart of the quality improvement mantra: Act for the individual, learn for the population. Learning about people's strengths, values, needs, and challenges is the foundation of the model for redesigning care in this Collaborative, and it is our springboard to better heath and lower costs.

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