Experts Suggest Interventions for High-Need Patients

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A group of experts identified 6 high-need populations and dimensions of successful care models to improve outcomes and reduce spending for these populations.

Health policy in the United States is shifting towards value-based care and, therefore, health organizations are focusing on the 5% of patients who are responsible for half of all healthcare costs. The National Academy of Medicine (NAM) in partnership with the Harvard T.H. Chan School of Public Health, the Bipartisan Policy, The Commonwealth Fund, and the Person Center on Healthcare, held workshops in order to advance the knowledge of how to best care for high-need patients, and published their findings in a report.

A recent article from JAMA Internal Medicine analyzed and summarized the different interventions for these patients that attempt to improve outcomes and reduce spending.

“High-need patients are a diverse group with high burden of medical comorbidities, functional limitations, disability, and social complexity,” the authors explained. “Therefore, different high-need segments require different services and workforce competencies to optimize patient care.”


The experts identified 6 high-need populations—children with complex needs, nonelderly disabled adults, frail elderly individuals, patients with major complex chronic conditions, patients with less severe but multiple chronic conditions, and patients with advancing illness.

The authors noted that determining these populations was necessary because each population of patients is unique and requires a customized strategy. Also, other than just the medical needs, the article noted the importance of considering the social, behavioral, and mental health factors within each population.

The experts also identified 4 dimensions of successful care models for high-need patients:

  1. Focus on service setting: successful care models tailor their service settings for a specific population with a set of needs
  2. Care model attributes: abilities to coordinate care and communication between patients and care team, promote patient and family engagement in self-care, and facilitate transitions among care settings
  3. Care delivery features: successful care models include access to timely data for feedback and patient monitory, extensive outreach mechanisms to patients’ homes, and a seamless integration of social services with the medical system
  4. Organizational culture: maintaining features such as emphasizing leadership at all levels, adapting and customizing care based on the changing needs of patients, and offering specialized workforce training

The experts also noted the obstacles physicians face in adopting more effective care models for their high-need patients. In order to overcome such challenges, physicians should participate in alternative payment models that allow integration of medical and social services and pay for all care of the patient.

Additionally, physicians and group practices should consider adoption of care models that target specific high-need patients. Clinicians should also work to track health outcomes, including patient-reported outcomes, for these populations.

“Too many of the current measures that target high-need patients focus on use of services, such as emergency department visits or hospitalizations,” the article concluded. “Clinicians have a critical role in both defining what is good care for these patients and how best to track it.”