Association member NYC Health + Hospitals (NYC H+H), with support from the Commonwealth Fund, has developed an operational guide to identify, understand, and treat patients with complex health, social, and behavioral needs in safety-net health settings. Essential hospitals serving complex patients can use the actionable information in this guide to replicate and implement NYC H+H’s process, including operational resources from the health system’s complex care clinic at Bellevue Hospital Center.
Complex care seeks to be person-centered and equitable, and it aims to work across sectors to meet individuals’ needs. This approach recognizes the structural barriers to health and supports patients and communities to address them. It works to break down silos that divide fields, sectors, and specialties — such as providers, nonprofit organizations, and health and human services — to build the integrated ecosystem necessary to provide holistic care.
In the complex care field, providers identify a subset of their patient population with complex health and social needs that requires a more holistic, interdisciplinary approach to care. These individuals make up a small percentage of a hospital’s patient population and account for a disproportionately high share of medical care and costs, but they still have unmet needs. By working across sectors to deliver integrated, individualized care for these individuals, health systems can come closer to achieving health equity.
While existing frameworks and implementation strategies can help identify and coordinate care for patients with complex needs, efforts to understand complexity do not fully consider diversity or the reality essential hospitals face. NYC H+H created a practical framework that considers the populations essential hospitals serve. The health system conducted a series of focus groups and targeted interviews with its providers to develop the holistic segmentation tool featured in this guide.
NYC H+H launched a complex care clinic at Bellevue in August 2018 to target resources to a patient segment. The Bellevue Primary Care Safety Net Clinic has served hundreds of people experiencing homelessness with complex chronic conditions and social needs. The clinic expanded to Woodhull Hospital in 2020.
Essential Hospitals Institute in July 2019 convened an advisory group of clinicians, complex care experts, and behavioral health experts to refine and provide feedback on the operational guide. Providers from essential hospitals shared their experiences and challenges and discussed how they might implement the guide in their own hospitals to streamline the identification, stratification, and treatment of complex patients.
NYC H+H’s finished product, The Complex Care Implementation Guide for Safety-Net Health Systems, outlines three approaches to supporting and meeting the needs of complex patients in their communities:
- risk scoring and stratification: using data and analytics to identify patients with complex needs;
- segmentation: combining analytics with clinical insight to understand patients with complex needs; and
- targeting: tailoring care models to fit needs and behaviors of patients with complex needs.
The guide was created in a PowerPoint format for busy providers to view and move through slides seamlessly, tailoring the embedded tools, tips, and examples to their own institution’s unique needs with respect to complex care.