I’ve seen a lot of complicated health issues up close and personal. My parents were what we often call patients with “complex needs.” My dad had a heart attack at age 42. Before that, he was in an auto accident that severely compromised his left leg and circulatory status. Underlying all these physical issues was trauma he never talked about. (My grandfather had committed suicide during the Great Depression and my father was the one who found him.)
Later, my mom, with COPD and eventually heart failure, was likely labeled a “frequent flyer” at her local emergency department. I witnessed first-hand the system issues that created gaps in her care, including a lack of information sharing among providers and patient education that overwhelmed her more than it helped. Although I know her health care providers tried, they were unable to keep her stable and out of the emergency room and hospital for long.
All these experiences — and my own time working as a nurse practitioner — made me wish for a more holistic, whole-person approach to health care.
A Different Way to View Complex Care
Researchers have determined that only 5 to 10 percent of the population account for 60 to 80 percent of US health care costs. The work of IHI and others on pursuing the Triple Aim has helped many health care providers understand that, while some of these folks require care that may be unavoidably expensive, many of them have needs that could be met more effectively, efficiently, and at lower cost by a better-designed health care system. Simultaneously improving the care experience, population health, and per capita costs compels us to look for improvement opportunities we may not have considered before.
Examples of this take many forms. Exemplar health systems like Cottage Health (Santa Barbara, California), Boston Children’s Hospital (Boston, Massachusetts) and Mount Sinai St. Luke’s (New York City, New York), for example, have made great strides in screening for and addressing social needs across the lifespan. These organizations have learned to develop staff roles, find available resources, and document cases for when screenings identify patients who may need help with food, housing, transportation, or other social determinants of health.
Other organizations — including the Camden Coalition’s National Center for Complex Health & Social Needs (Camden, New Jersey), Surge Advisors (Starkville, Mississippi), Mississippi Business Group on Health (Madison, Mississippi), and Gunderson Health System (LaCrosse, Wisconsin) — have designed innovative ecosystems to provide better complex care. Regional One Health (Memphis, Tennessee), for example, created an Ecosystem Asset Map and developed partnerships with providers of housing, transportation, and behavioral health to provide more holistic care for their patients.
Compared to when I was first asked to lead IHI’s complex care redesign work six years ago, there is now a deeper and wider knowledge base that health care systems and communities can turn to for guidance to better meet the needs of individuals with complex social and health needs. Some helpful resources include:
These websites include useful tools and some of them feature inspiring success stories. While it’s true that we have a long way to go, it’s gratifying for me to hear about patients — some of them not so different from my parents — getting what they need and thriving. It feels like coming home.
Cory Sevin, RN, MSN, is a Senior Director at the Institute for Healthcare Improvement. She will be facilitating A31: How to Screen for and Address Social Needs Across the Lifespan at this year’s IHI National Forum on Tuesday, December 10 from 9:30 AM to 10:45 AM and SW02: Methods for Improving Outcomes for Complex Care Populations, a Storyboard Walkaround Session, on Tuesday, December 10 starting at 9:30 AM.