Improving outcomes and reducing costs in the treatment of 'high-needs patients'

Nearly half of the nation's spending on health care is driven by 5 percent of patients, and improving health outcomes and curbing spending in health care will require identifying who these high-needs patients are and providing coordinated services through successful care models that link medical, behavioral, and community resources, says a new National Academy of Medicine special publication. The needs of this population extend beyond care for their physical ailments to social and behavioral services that are often central to their overall well-being. As a result, addressing clinical needs alone will not improve their health outcomes or reduce health care costs. The publication—which summarizes presentations, discussions, and scientific literature from a three-part workshop series—examines the key characteristics of high-needs patients; the use of a patient categorization scheme, or a taxonomy, as a tool to inform and target care; promising care models and attributes to better serve high-needs patients; and areas of opportunity to support the spread and scale of evidence-based programs.

"As the nation examines how to drive down the costs of health care, there are opportunities for action to improve the care and reduce the cost of delivering that care for one of the most expensive and challenging populations of the current health care system: high-needs patients," said Victor J. Dzau, president of the National Academy of Medicine.

"Improving the care management of high-needs patients—while balancing quality and associated costs—will require bold actions and system payment reform efforts by a broad range of stakeholders at multiple levels," said Peter Long, chair of the planning committee for the NAM workshop series, and president and chief executive officer, Blue Shield of California Foundation.

Understanding the characteristics of high-needs patients is the first step in determining how to improve care. However, consensus on those defining characteristics has been slow to evolve, the publication says. While the high-needs population is diverse, three criteria could help define and identify this population: total accrued health care costs, intensity of care utilized for a given period of time, and functional limitations. Functional limitations include limitations in activities of daily living—such as dressing, bathing, self-feeding, and grooming—or limitations in instrumental activities of daily living that support an independent lifestyle—such as housework, shopping, managing money, taking medications, or using transportation.

In terms of demographics, available literature indicates that high-needs individuals are disproportionately older and less educated. They are also more likely to be publicly insured, have fair-to-poor self-reported health, and be susceptible to lack of coordination within the healthcare system. Therefore, improving outcomes for this population requires assurance of attention to an individual's functional, social, and behavioral needs—largely through social and community services.

Understanding how to care effectively for high-needs patients requires ascertainment of the key factors driving the needs for of each individual. Because this patient population is heterogeneous, those factors will differ for different segments of the population. Therefore, the use of a practical taxonomy that helps group individuals by the care they most need—as well as when, how, and how often they might need it—can inform decisions about how to serve these patients more effectively.

In the course of the workshop meetings, a taxonomy working group identified for discussion the taxonomic elements that might help align high-needs patients with the care models that target their specific circumstances. While the success of even the best care model will depend on the particular needs and goals of the patient group a model intends to serve, which vary for different segments of high-needs patients, all successful care models aim to foster effectiveness across three domains: health and well-being, care utilization, and costs. The planning committee identified 14 successful care models for high-needs patients and cross-referenced those models to the segments of the proposed taxonomy that could be served if health systems leaders could match the needs of their patients to appropriate models within this menu of evidence-based approaches.

A number of barriers currently prevent the spread or sustainability of successful care models including the misalignment between financial incentives and the services necessary to care for high-needs patients, health system fragmentation, workforce training issues, and disparate data systems that cannot easily share needed information. The publication discusses these barriers as well as strategies for addressing them.

Overarching opportunities for action and reform identified in the publication include:

• refining the starter taxonomy based on real-world use and experience to facilitate the matching of individual need and functional capacity to specific care programs;
• integrating and coordinating the delivery of medical, social, and behavioral services to reduce the burdens on patients and caregivers;
• developing approaches for spreading and scaling successful programs and for training the workforce capable of making these models successful;
• promoting payment reform efforts that further incentivize the adoption of successful care models and the integration of medical and social services;
• establishing a small set of proven quality measures appropriate for assessing outcomes, including return on investment, and continuously improving programs for high-needs individuals; and
• creating road maps and tools to help organizations adopt models of care suitable for their particular patient populations.

With funding from the Peterson Center on Healthcare, and in collaboration with the Harvard T.H. Chan School of Public Health, the Bipartisan Policy Center, and The Commonwealth Fund, the National Academy of Medicine convened this collaborative effort with health care leaders to accelerate improvements in the management of care for high-needs patients. The views presented in this special publication are those of the authors and do not represent formal consensus positions of the NAM; the National Academies of Sciences, Engineering, and Medicine; or the authors' organizations.