Addressing the unmet medical and social needs of complex patients

Complex patients have multiple chronic conditions and often struggle to manage them. They may have functional limitations, or a combination of vulnerabilities including 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. Implementing the models of care described in this paper could mean great progress in lowering cost, improving quality of care and reducing disparities.