Testing a New Approach for Identifying High-Need, Complex Patients Based on Clinical and Patient Activation Profiles

To achieve high levels of quality and efficiency, health systems must develop interventions that target patients with the greatest care needs and costs. Typically, health systems have focused their effort on those patients with the greatest disease severity. This project will test the value of a new approach to identifying high-need, high-cost patients that relies not just on measures of clinical severity but also on patients’ level of “activation”— the knowledge, motivation, and confidence essential to managing one’s own health and health care. The research team will examine the extent to which patient activation scores improve the ability of health systems to predict health and cost outcomes for this population over two- and three-year time frames. The findings will inform health systems and policymakers of the potential value in tailoring the intensity of care management programs based on a more comprehensive risk profile.