Complex Care Playbook for Safety-Net Health Systems

The New York City Health and Hospitals Corporation (H+H) has developed, pilot-tested, and published in the peer-reviewed literature a method for stratifying its entire patient population to identify high-need, high-cost individuals. This project will refine and pilot the next step in the process through segmentation of high-need patients into subgroups. The H+H team will work iteratively with leadership and frontline providers from across the system’s 17 facilities to obtain feedback about the accuracy and usefulness of the segmentation approach. The team also will review quarterly data about patient demographics, quality of care, and utilization. Based on this mix of qualitative and quantitative feedback, H+H will refine the categorization of high-need patients into subgroups and help optimize the health system’s efforts to target interventions to patients.