This resource reviews efforts of academic medical centers (AMCs) to improve care for patients with complex needs, and the opportunities for AMCs to contribute to better care throughout the health system.

• More AMCs are seeking to improve care for patients with complex needs, in part because value-based payment models make it financially beneficial.
• Six key program features have proven results for improving care for this population, including targeting interventions to those patients who are most likely to benefit; comprehensively assessing patients’ needs; and partnering with social service providers to address patients’ non-clinical needs.

AMCs have a critical role to play in influencing the nation’s next generation of medical professionals, by teaching them to address the social determinants of health, work in team-based environments, and effectively communicate with patients