WIHI: New Models for Patients with Multiple Health and Social Needs

Date: June 23, 2011


  • Catherine Craig, LMSW, MPA, Director of Health Integration – National Programs, Common Ground
  • Maria Raven, MD, MPH, MSc, Assistant Professor of Emergency Medicine, New York University School of Medicine
  • Geraint Lewis, MA, MSc, FRCP, FFPH, Public Health Physician and Senior Fellow, The Nuffield Trust, UK

There isn’t a health care provider anywhere in the US who hasn’t witnessed the disconnect between a patient with multiple health and social needs and the systems available to help that individual. The gap between what’s needed and what’s available (and what’s paid for) is often staggering. Stories abound of doctors and nurses and social workers painstakingly trying to patch together services that might function as an alternative to the hospital’s emergency department, get a prescription filled, get someone a hot meal… and on it goes. There are communities in the US and other countries that have worked for years to do things better but, wherever you go, patients with multiple illnesses combined with a lot of instability in their lives present challenges far beyond the capability and current design of most health care systems.

Nothing like a challenge! WIHI has been tracking some timely work and research that goes by such exotic names as “predictive modeling” and “virtual wards” — or is as basic as care coordination and supportive housing. WIHI host Madge Kaplan talks with key experts leading the way in these areas to discuss new ways to work with patients to address underlying needs and manage chronic health problems that lessen dependence on expensive health care services. The good news is that wherever new models are being tried, they’re making a real, tangible difference.

Related information to this WIHI program includes a new IHI white paper on innovations in care coordination, co-authored by Catherine Craig, and Atul Gawande’s article, “The Hot Spotters," from the January 2011 New Yorker.


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