Addressing the Social and Medical Needs of Complex Patients


Complex patients have multiple chronic conditions and often struggle to manage them. They may have a number of functional limitations, or a combination of vulnerabilities that are exacerbated by social disadvantages such as homelessness, low income, behavioral health issues, or being a racial and ethnic minority.  

Because this is a very high cost population that often experiences unmet social needs and care coordination failures, there is tremendous opportunity to improve the lives of these patients and possibly reduce net social and health spending. Models of care that are data driven, tailored to patient needs and integrate care from healthcare and social service providers are extremely promising and deserve the sustained attention of policymakers and advocates.  

National Resources

The Hub's Inventory of Local Programs Targeting Complex Patients - This inventory contains profiles of nearly a hundred programs across 36 states and territories. To qualify for inclusion, programs must specifically target complex patients and go beyond medical care coordination to offer either a level of social services integration or a program that specifically addresses socioeconomic disparities. Programs or models operating in multiple states are listed under "Multistate."

National Center for Complex Health and Social NeedsLaunched in 2016, this center aims to improve outcomes for patients with complex medical, psychological, and social needs. It works to coalesce a new field of healthcare by bringing together a broad range of clinicians, researchers, policymakers, and consumers who are developing, testing, and scaling new models of team-based, integrated care.

The Play Book - Five foundations partnered with the Institute for Healthcare Improvement to create a dynamic website that highlights the challenges facing adults with complex health and social needs and provides direction on how to meet those needs through a variety of resources that detail care models, policies and more.

Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value  and Health - This National Academy of Medicine publications summarizes insights and perspectives on how to better manage the care of the high-need patient population from three workshops held between July 2015 and October 2016.

Identifying the Complex Patient

Successful Models of Care

  • Camden Coalition and Healthcare Hotspotting. The Camden Coalition is a citywide coalition of hospitals, primary care providers, and community representatives that collaborate to deliver better healthcare to our most vulnerable citizens. Hotspotting uses data to discover the outliers, understand the problem, dedicate resources, and design effective interventions. It is a movement for a new system of multidisciplinary, coordinated care that treats the whole patient and attends to the non-medical needs that affect health: housing, mental health, substance abuse, emotional support.

More models can be found in our Inventory of Local Programs Targeting Complex Patients.

Financing Integrated Models

Data Systems for Models