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Table.  
Patient Subpopulations and Their Drivers of Spendinga
Patient Subpopulations and Their Drivers of Spendinga
1.
Long  P, Abrams  MK, Milstein  A,  et al.  Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: National Academy of Medicine; 2017.
2.
Cohen  S.  The Concentration of Health Care Expenditures and Related Expenses for Costly Medicaid Conditions. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
3.
Peikes  D, Chen  A, Schore  J, Brown  R.  Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries.  JAMA. 2009;301(6):603-618.PubMedGoogle ScholarCrossref
4.
Congress of the US Congressional Budget Office. High-Cost Medicare Beneficiaries. Washington, DC: Congress of the US Congressional Budget Office; 2005.
5.
Joynt  KE, Figueroa  JF, Beaulieu  N, Wild  RC, Orav  EJ, Jha  AK.  Segmenting high-cost Medicare patients into potentially actionable cohorts.  Healthc (Amst). 2017;5(1-2):62-67.PubMedGoogle ScholarCrossref
6.
Figueroa  JF, Joynt Maddox  KE, Beaulieu  N, Wild  RC, Jha  AK.  Concentration of potentially preventable spending among high-cost Medicare subpopulations.  Ann Intern Med. 2017;167(10):706-713.PubMedGoogle ScholarCrossref
7.
Miller  A, Cunningham  M, Ali  N.  Bending the cost curve and improving quality of care in America’s poorest city.  Popul Health Manag. 2013;16(suppl 1):S17-S19.PubMedGoogle ScholarCrossref
8.
Counsell  SR, Callahan  CM, Buttar  AB, Clark  DO, Frank  KI.  Geriatric Resources for Assessment and Care of Elders (GRACE).  J Am Geriatr Soc. 2006;54(7):1136-1141.PubMedGoogle ScholarCrossref
9.
Institute for Healthcare Improvement. Better Care Playbook. 2017; http://www.bettercareplaybook.org/. Accessed November 15, 2017.
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    Evidence to Practice
    June 2018

    Approach for Achieving Effective Care for High-Need Patients

    Author Affiliations
    • 1Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
    • 2Department of Medicine, Harvard Medical School, Boston, Massachusetts
    • 3Division of General Internal Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
    JAMA Intern Med. 2018;178(6):845-846. doi:10.1001/jamainternmed.2018.0823
    Source of Review

    Recently, the National Academy of Medicine (NAM), in partnership with the Harvard T. H. Chan School of Public Health, the Bipartisan Policy Center, The Commonwealth Fund, and the Peterson Center on Healthcare, which funded this initiative, held a series of workshops to advance our collective knowledge about how best to care for high-need patients. These workshops and their findings culminated in a NAM report titled Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health.1 Most of the evidence for this report ranged from level 2 (prospective comparative studies) to level 5 (expert opinions). In addition, a consensus decision-making process was used to identify the high-need patient taxonomy and successful care models.

    Background

    As US health policy shifts toward value-based care, health care organizations are increasingly turning their attention to the small proportion of individuals who account for most of health care spending. In the United States, 5% of patients are responsible for half of all health care costs.2 Optimizing care for these patients has been difficult, with most interventions failing or doing little to improve outcomes or reduce spending.3,4

    Summary of Findings
    Use of Patient Taxonomies to Target Care

    High-need patients are a diverse group with high burden of medical comorbidities, functional limitations, disability, and social complexity.5 Therefore, different high-need segments require different services and workforce competencies to optimize patient care. After an extensive review of the literature and expert panel discussions, the workshop members identified 6 high-need populations. A taxonomy workgroup used a consensus-driven process to define these populations, which were then presented in a public workshop for feedback and refinement. The final 6 categories of high-need populations were children with complex needs, nonelderly disabled adults, frail elderly individuals, patients with major complex chronic conditions, patients with less severe but multiple chronic conditions, and patients with advancing illness (Table).

    Each of these populations is unique and needs a customized strategy based on its care requirements. For example, the report highlights research that found that costs for high-need, nonelderly disabled patients are related to drugs, whereas costs for high-need frail elderly individuals are related to inpatient and post–acute care use.5,6 In addition, although frail elderly individuals represent less than 10% of the Medicare population, they account for more than half of potentially preventable spending for admissions related to ambulatory care–sensitive conditions, such as dehydration and urinary tract infections.6 These insights suggest that unless the interventions are targeted, they are unlikely to be effective.

    In addition to medical needs, social risk and behavioral or mental health factors that may affect a patient’s health within each segment should be assessed. Social factors include socioeconomic status, social isolation, community deprivation, and housing insecurity. Behavioral health factors include substance abuse and serious mental illness. The presence of any of these factors within each segment can substantially alter health care use and contribute to poor health outcomes; therefore, different approaches are required to treat patients who have these risk factors.

    Features of Successful Care Models for High-Need Patients

    The report identified 4 dimensions of successful care models for high-need patients: (1) focus on service setting, (2) care model attributes, (3) care delivery features, and (4) organizational culture.

    The first dimension is that successful care models tailor their service settings for a specific population with a set of needs, such as enhanced primary care and integrated care models. For example, the Geriatric Resources for Assessment and Care of Elders Team Care model has improved quality for low-income elderly patients with multiple chronic conditions.7

    Second, specific attributes of successful models are highlighted in the report. Successful practices can identify and match patients with interventions likely to be beneficial. Such matching requires that practices understand the full spectrum of patient needs. Other attributes include an ability to coordinate care and communication between patients and care team, promote patient and family engagement in self-care, and facilitate transitions among care settings. One exemplary model is the Camden Coalition Project, which is an integrated cross-disciplinary care model that focuses on medical and social risk interventions and behavioral health services to meet the needs of low-income, vulnerable patients.8

    Third, common care delivery features in successful models include access to timely data for feedback and patient monitoring, extensive outreach mechanisms to patients’ communities and home, seamless integration of social services with the medical system, and standard protocols for appropriate patient follow-ups.

    Fourth, organizational culture is a key dimension of successful care models. Common operational features include emphasizing leadership at all levels, adapting and customizing care based on the changing needs of patients, and offering appropriate, specialized workforce training.

    Implications for Practicing Physicians

    Physicians currently face several obstacles in adopting more effective care models for high-need patients. These obstacles include financial incentives that make it difficult to provide the necessary services for these individuals, staff workforce training issues, and disparate data systems that cannot easily share or combine essential information on social factors with medical information. To overcome these challenges, physicians can engage in the following strategies.

    First, physicians should seek participation in alternative payment models that allow integration of medical and social services and pay for all care of the patient as opposed to piecemeal payments, which are common with fee-for-service care. Currently, several private payers are engaging in these efforts with physicians and hospitals, such as the alternative quality contract of Blue Cross Blue Shield of Massachusetts. Public payers are also shifting toward payment models, such as accountable care organizations. As these alternative payment models proliferate, it is critical that physicians push for additional services, such as better access to mental health or substance abuse treatments. Many new models encourage patients to receive care at home and pay for training of staff to visit and care for patients at home.

    Second, physicians and group practices should consider adoption of care models that target specific high-need populations. The NAM report not only offers a promising starting point for identifying segments of high-need patients but also points to resources such as the Institute for Healthcare Improvement Better Care Patient Playbook,9 which was developed to help clinicians implement evidence-based interventions that can improve care for specific segments of the high-need patient population.

    Third, few metrics are available to assess improved outcomes for high-need patients. Clinicians can play a critical role by tracking health outcomes, including patient-reported outcomes, for these populations and ensuring that new care models are not only saving money but also improving care. Achievement of this goal requires rigorous, formal, and ideally prospective evaluations of any new care model’s influence on patient outcomes. Too many of the current measures that target high-need patients focus on use of services, such as emergency department visits or hospitalizations. Clinicians have a critical role in both defining what is good care for these patients and how best to track it.

    Conclusions

    Health care practitioners need to take a multifaceted approach to improve care for high-need patients. This approach includes increasing the use of patient taxonomies to appropriately match patients with the right interventions; designing effective care models that address patients’ medical, social, and behavioral needs; and engaging in payment models that allow and reward care of vulnerable patients whose health and well-being depends on integrated, high-quality care.

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    Article Information

    Corresponding Author: Ashish K. Jha, MD, MPH, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 42 Church St, Boston, MA 02138 (ajha@hsph.harvard.edu).

    Published Online: April 9, 2018. doi:10.1001/jamainternmed.2018.0823

    Conflict of Interest Disclosures: Drs Figueroa and Jha reported receiving research grants from the Peterson Center on Healthcare and The Commonwealth Fund, which informed the report. Both authors also reported serving on the planning committee for the National Academy of Medicine workshop series on Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health and served on the taxonomy workgroup.

    References
    1.
    Long  P, Abrams  MK, Milstein  A,  et al.  Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: National Academy of Medicine; 2017.
    2.
    Cohen  S.  The Concentration of Health Care Expenditures and Related Expenses for Costly Medicaid Conditions. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
    3.
    Peikes  D, Chen  A, Schore  J, Brown  R.  Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries.  JAMA. 2009;301(6):603-618.PubMedGoogle ScholarCrossref
    4.
    Congress of the US Congressional Budget Office. High-Cost Medicare Beneficiaries. Washington, DC: Congress of the US Congressional Budget Office; 2005.
    5.
    Joynt  KE, Figueroa  JF, Beaulieu  N, Wild  RC, Orav  EJ, Jha  AK.  Segmenting high-cost Medicare patients into potentially actionable cohorts.  Healthc (Amst). 2017;5(1-2):62-67.PubMedGoogle ScholarCrossref
    6.
    Figueroa  JF, Joynt Maddox  KE, Beaulieu  N, Wild  RC, Jha  AK.  Concentration of potentially preventable spending among high-cost Medicare subpopulations.  Ann Intern Med. 2017;167(10):706-713.PubMedGoogle ScholarCrossref
    7.
    Miller  A, Cunningham  M, Ali  N.  Bending the cost curve and improving quality of care in America’s poorest city.  Popul Health Manag. 2013;16(suppl 1):S17-S19.PubMedGoogle ScholarCrossref
    8.
    Counsell  SR, Callahan  CM, Buttar  AB, Clark  DO, Frank  KI.  Geriatric Resources for Assessment and Care of Elders (GRACE).  J Am Geriatr Soc. 2006;54(7):1136-1141.PubMedGoogle ScholarCrossref
    9.
    Institute for Healthcare Improvement. Better Care Playbook. 2017; http://www.bettercareplaybook.org/. Accessed November 15, 2017.
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