Health care costs are heavily concentrated among people with multiple health
problems. Often, these are older adults living with frailty, advanced illness, or other
complex conditions. In 2014, the New York–based Commonwealth Fund, a private,
independent foundation, established the International Experts Working Group on
Patients with Complex Needs through a grant to the London School of Economics
and Political Science. The group’s purpose was to outline the prerequisites of a
high-performing health care system for “high-need, high-cost” patients and to
identify promising international innovations in health care delivery for meeting
needs of these patients. Drawing on international experience, quantitative and
qualitative evidence, and its members’ collective expertise in policy and program
design, implementation, and evaluation, the international working group sought
to articulate the principles that underpin high performance for this complex
population in health systems around the world.
What follows are the group’s top recommendations based on these principles. All
10 present challenges, with some requiring profound paradigm shifts—for instance,
away from disease-specific care delivery and toward more patient-centered
approaches, or away from the single-provider model and toward cooperation and
teamwork. Their implementation, however, has the potential to transform care
and quality of life for millions. The selected international models that follow the
recommendations represent some of the promising frontline care innovations that
illustrate the principles laid out here.
Make care coordination a high priority.
Because patients with complex needs receive treatment from a wide range of providers, their
care often becomes fragmented. This can result in more hospitalizations and lower patient
satisfaction. What these patients need is a dedicated person who is responsible for coordinating
all their care. This could be the patient’s primary care physician, but increasingly health
care organizations are employing staff specifically tasked with coordinating treatment for
complex patients. Although better coordination should lead to better care, it will less often
save money. It is therefore especially important to identify and remove financial disincentives
to care coordination.
Identify patients in greatest need of proactive, coordinated care.
Several methods have been developed to identify patients with complex needs. Generally
they use data drawn from medical records, sometimes supplemented by professional judgment.
The aim is to identify patients at risk for poor outcomes, such as unnecessary hospital
admissions, and provided targeted, proactive, team-based care. While a number of validated
models exist to predict patients’ health care utilization and costs, individual countries will
likely need to adapt these models based on the types of data they have available.
Train more primary care physicians and geriatricians.
In most OECD member countries, the number of subspecialists has increased at a much
higher rate than the number of generalists. This trend has led to fragmented care and needs
to be reversed. To meet the needs of aging populations, more family physicians and geriatricians,
in particular, will be needed. Medical school curricula and training programs should be
altered to support this shift.
Facilitate communication between providers—for example,
through clinical record integration.
It is important that providers treating a patient with complex needs are able to share important
data about that patient; this ensures clinicians have the information they need, when
they need it. Ideally, this is accomplished by a single electronic record for all the patient’s
medical care. Also critical is good and timely provider communication, including the prompt
relay of information to the primary care physician following hospitalization and specialist
visits and the sharing of care plans with after-hours and emergency services.
Engage patients in decisions about their care.
For the patient with multiple health conditions, treatment that adheres to evidence-based
guidelines for each individual condition can lead to an unacceptable burden of treatment,
adverse interactions between treatments, and risks from polypharmacy. Patients with complex
conditions need to be part of an open discussion of the benefits and risks of individual
treatments. Such a process allows them to bring their own needs, preferences, and hopes
into the treatment conversation.
Provide better support for caregivers.
Elderly people and those with complex needs often receive care from family members and
friends. They are usually unpaid and often provide support around-the-clock. Health services
need to take steps to identify and support these informal caregivers. Support might include respite
care to provide relief for caregivers and assistance to help them look after their own health.
Redesign funding mechanisms to meet patients’ needs.
Current funding mechanisms and payment incentives often exacerbate the problems of fragmented
care. For example, fee-for-service encourages the overprovision of specialist services;
capitation- and salary-based payments may lead to undertreatment; and quality incentives
tend to prioritize only those aspects of care that are most easily measured. Payments systems
for complex patients need to be redesigned so that they reduce barriers to collaboration,
adequately compensate for the complexity of cases treated, and incentivize hospitals to work
with community providers.
Integrate health and social services, and physical and mental
The separation of health and social care fails to recognize some patients’ closely related needs
for both types of care. Constrained social service spending may also lead directly to inefficient
use of health care resources—for example, when patients are unable to be discharged from
the hospital because of a lack of support available in the community. Care for patients with
complex needs therefore requires close cooperation between the two sectors.
Failure to integrate physical and mental health care also causes problems for patients with
complex needs. Care for mental health must be integrated with physical health care, with
multidisciplinary teams ensuring that physical and mental health problems are addressed
together in a timely fashion.
Engage clinicians in change and train and support clinical leaders.
Implementing these recommendations will challenge notions of professional autonomy,
established beliefs, and engrained ways of working. Clinical leadership is key to delivering
successful change, and the clinicians leading change need support from local managers to
ensure that local administrative systems and budgetary arrangements do not stifle change.
Clinicians may also benefit from formal leadership training and opportunities to meet with
peers on a regular basis.
Learn from experience and scale up successful projects.
Different solutions will suit different environments. Policymakers and health care managers
should provide opportunities for sharing experiences and learning from success as well as
failure. It is important to understand that successful projects tend to develop iteratively over
time—and sometimes over a long period.
Selected Profiles of Care Models for Patients with Complex Needs
CANADA: Mount Sinai Hospital Acute Care for Elders (ACE) Strategy
LOCATION: Toronto, Ontario, Canada
YEAR ESTABLISHED: 2010
Mount Sinai Hospital developed a
comprehensive, integrated approach to improve
care for hospitalized older adults and older adults at
high risk of hospitalization, particularly because of
functional, cognitive, social, or other problems.
To improve the delivery and quality
of care, patient and system outcomes in all older
patients, and those older patients at especially high
risk of poor outcomes.
All patients age 65 and older
admitted with an acute medical condition. High-risk
patients are identified in emergency department
(ED) based on having any three or more of: 1) recent
decline in functional abilities; 2) recent change in
cognition or behavior; 3) geriatric syndrome (e.g.,
falls, incontinence, acute or chronic pain); 4) complex
social issues; or 5) Identification of Seniors at Risk
(ISAR) score ≥2. Complementary community-based
programs also identify and support high-risk patients.
Program enrolled approximately 10,500 patients
between 2010 and 2015.
KEY FEATURES AND INTERVENTIONS
ISAR screening for all older ED patients, with
additional support from geriatric emergency
management nurses. High-risk medical patients are
prioritized to be cared for under Acute Care for Elders
(ACE) protocol and, when possible, by designated
ACE inpatient medical unit. All older patients have
access to hospitalwide consultation liaison services
in geriatrics, psychiatry, and palliative medicine
and to volunteer-based Hospital Elder Life Program
(HELP). All professionals are educated in geriatric
care. Additional models strengthen community
care and improve care transitions; Integrated Client
Care Program provides intensive care coordination
for targeted high-risk/high-use patients, while
community outreach teams provide short-term homeand
community-based supports to patients at risk of
losing independence. ACE strategy integrates these
interventions to create seamless, interprofessional,
technology-enabled integrated team-based delivery
model spanning the care continuum.
Geriatricized order sets
and care protocols to support safer evidence-based
care; tracking systems to monitor flow of ACE
patients throughout Mount Sinai Hospital in real
time and support timely transfer to ACE unit; secure
e-mail notification and flagging systems to allow
primary care, home care, emergency, and inpatient
care providers to communicate effectively; and risk
identification tools (ACE Tracker) to support early
identification of high-risk patients.
FINANCING AND PAYMENT METHODS
Usual funding through global block payments for
hospitals and other community-based agencies.
Physicians paid fee-for-service; other professionals are
salaried. Hospital budget structures create incentives
to reduce admissions and length of stay. No modelspecific
performance tracking system, using balanced scorecard
and regional benchmarking to identify areas for
improvement. Pre/post implementation comparisons.
and post-implementation periods,
there was 53 percent overall increase in annual
admissions of patients age 65 and older within
Toronto’s fast-growing population (due to trend of
increasing ED visits). Mount Sinai has maintained
region’s lowest admission rate of older patients—25
percent, 18 percent lower than regional admission
rate. For those admitted to hospital, there was 28
percent decrease in mean length of stay; 13.4 percent
decline in readmissions; reduction in “alternate level
of care” (“bed blocker”) days per patient of 20 percent;
and increase in patients discharged directly to home.
Average direct cost of care per patient reduced by 23
percent, and general inpatient medical beds reduced
by 18.2 percent.
Personal communication with Samir Sinha
S. K. Sinha, S. L. Oakes, S. Chaudhry et al., “How to Use the ACE Unit to Improve Hospital Safety and Quality for Older Patients: From ACE Units to
Elder-Friendly Hospitals,” in M. L. Malone, E. Capezuti, R. M. Palmer, eds., Acute Care for Elders—A Model for Interdisciplinary Care (Springer, 2014)
S. K. Sinha, J. Bennett, T. Chalk, “Establishing the Effectiveness of an Acute Care for Elders (ACE) Strategic Delivery Model in Delivering Improved
Patient and System Outcomes for Hospitalized Older Adults,” Journal of the American Geriatrics Society (2014), 62:S143
FRANCE: Personalized Health Plan for Elderly at Risk of Autonomy Loss (PAERPA)
Nine administrative regions across
In nine pilot regions across
France in 2013–14; seven additional regions in 2016
in order to ensure full deployment on the French
territory and provide PAERPA coverage to a total of
French residents age 75 or older
are 9 percent of the population but accrue 22
percent of health expenditures. The High Council
for the Future of Health Insurance identified
several shortcomings in elder care: lack of
referral pathways from primary care to specialist
physicians, burdens on informal caregivers
resulting in “respite” hospital admissions, hospitals’
lack of attention to geriatric patients’ needs,
insufficient availability of health care professionals
in nursing homes, capacity shortfalls in nursing
homes delaying hospital discharge, regional
disparities in the availability of social support and
personal care services, and lack of coordination
between hospitals and social service facilities.
To improve frail elders’ quality of life,
better coordinate their care, and reduce caregiver
Those age 75 or older who:
live in long-term care facilities; are admitted to
hospital via emergency departments; are frail; take
certain prescription drugs; or have one or more
chronic condition. Eligibility for a personal care
plan is assessed by a primary care physician or care
coordinator. Across regions, 6 percent to 14 percent
of elders were enrolled.
KEY FEATURES AND INTERVENTIONS
features, including eligibility criteria, vary by
region. Common features include systematic
identification of those at risk; education
for elders and their caregivers; professional
education on frail elders’ needs; personal care
plans; and interventions to reduce the risk of
falls. Integrated health and social services are
provided through mobile geriatric teams; respite
facilities for informal caregivers; telemedicine; a
fast-track application for welfare benefits; and
temporary stays in long-term care facilities to
facilitate transitions from hospital to home. Nurse
coordinators coordinate the work.
A secure e-mail system
facilitates communication and web-based systems
provide information to patients and professionals.
Although special legislation permits data sharing
among members of care teams, medical records are
not yet widely shared.
FINANCING AND PAYMENT METHODS
funding for information systems, coordination
units, financial incentives, and additional services.
Regional Health Authorities fund pilot projects
through social security and have autonomy in
funding local variations. Providers are paid as
usual. In addition, an incentive of €100 per elderly
patient with a personal care plan is shared between
primary care physicians and other involved
professionals. Long-term care institutions receive
€53 per day for temporary residents in transition
out of hospital.
of process indicators (e.g., number of personal
care plans created) are mandatory in local
implementations. Qualitative and health economic
evaluations are under way at the national level.
Not yet available.
Personal communications with Marie-Aline Bloch, Sebastien Gand, and Elvira Periac
Cour des comptes, Le maintien à domicile des personnes âgées en perte d’autonomie (2016)
Y. Bourgueil, J.-B. Combes, N. Le Guen et al., Atlas des territoires pilotes PAERPA—Situation 2012 (IRDES, 2015)
Ministère des Affaires sociales et de la Santé, Le dispositif Paerpa 2016, http://social-sante.gouv.fr/systeme-de-sante-et-medico-social/parcours-despatients-
UNITED STATES: Commonwealth Care Alliance “One Care” Program
Massachusetts, United States
Adults under age 65 who are
eligible for both Medicaid and Medicare are a
particularly vulnerable group, with complex and
often overlooked needs.
To provide enhanced primary care and
care coordination for dually eligible Medicare and
Medicaid beneficiaries through multidisciplinary
teams that include physicians, nurses, and mental
health and geriatric specialists, and to generate
savings from reduced hospitalizations and
One Care demonstration, Commonwealth Care
Alliance (CCA) provides coverage to more than
11,000 dually eligible, nonelderly beneficiaries—
the majority of state of residents enrolled in the
demonstration. Roughly 80 percent have multiple
chronic health conditions, mental health problems,
or functional limitations due to physical and
KEY FEATURES AND INTERVENTIONS
Interdisciplinary care teams—nurse practitioners,
physician assistants, behavioral health and
addiction clinicians, social workers, community
health workers, and others—assemble around
medically complex patients, helping to identify
their unmet medical, behavioral health, and
social service needs and deploying resources
using flexible benefits. Individualized care plans,
developed by clinicians and members, guide
resource allocation for long-term care, durable
medical equipment, behavioral health services, and
other key components. Care delivery innovations,
including a community paramedicine program
and community psychiatric respite facilities, shift
care from acute settings into the home and the
community (where appropriate), at lower cost.
Web-based and shared
electronic medical record.
FINANCING AND PAYMENT METHODS
CCA receives a risk-adjusted, per member per
month, capitated blended payment from both
Medicare and the state Medicaid program. CCA
then bears full financial risk for the total cost of
care, including long-term services and supports,
acute and postacute care, pharmaceuticals, and
primary care. Given the complexity and cost of
CCA’s beneficiaries, these payments are substantial:
In 2015, CCA received $386 million from the
Medicaid and Medicare programs, and $273
million for the 15 months ending in December
2014. The state’s Medicaid contribution ranges
from a few hundred dollars per member per month
for relatively healthy patients to $9,000 or more
for patients with extended stays at long-term
care facilities. The base rate for Medicare Part A/B
capitation payments are in the range of $770 to
$960 per member per month.
A pre/post study of 4,500
CCA One Care enrollees, without control group.
Enrollees had 7.5 percent
fewer hospital admissions and 6.4 percent fewer
emergency department visits than in the prior 12
months and greater use of long-term services and
supports. A majority of enrollees said they were
satisfied with the program. A preliminary analysis
found that use of inpatient facilities and inpatient
psychiatric days decreased.
Commonwealth Care Alliance (2016), www.commonwealthcarealliance.org/about-us/history
S. Klein, M. Hostetter, and D. McCarthy, The “One Care” Program at Commonwealth Care Alliance: Partnering with Medicare and Medicaid
to Improve Care for Nonelderly Dual Eligibles (Commonwealth Fund, Dec. 2016), http://www.commonwealthfund.org/publications/casestudies/