This Play was developed by the Institute for Healthcare Improvement (IHI) based on their work in the Better Health and Lower Costs for People with Complex Needs collaborative, which ran from 2014-2017.
Understanding the needs and assets of people with complex needs is critical to designing an effective and sustainable care model. The Three-Part Data Review is a systematic process for understanding the root cause of high utilization.
The goal of this play is to help you choose your population, and it can also help you engage patients and families in person-centered co-design.
- Review available population data to identify overall patterns (e.g., utilization, diagnosis codes, age, health insurance coverage) that may also impact the chosen population segment.
- Interview care providers to learn their perspective on the population’s greatest needs and assets. Consider asking providers questions such as:
- Which patient groups have complex needs and are likely to have high health care costs (e.g., frail older adults, children with three or more health conditions)?
- What are the needs and assets of people who are not well-served by the current health care system?
- What are the biggest challenges your organization faces in fostering good patient outcomes?
- What individual or community assets help patients get their needs met?
- Interview 10 to 15 patients in the chosen population segment to learn their perspectives on assets and needs. Consider asking patients questions such as:
- What is most important to you about your health and health care?
- What are your health goals?
- What are the challenges you face in managing your health, health care, and living situation?
- What would help you with these challenges?
- Use all three data sources to identify the root causes of high utilization and poor health outcomes.
- Knowing the characteristics of your chosen population is the start to understanding and selecting your population segment with complex needs and high costs.
- There are several methods that you can use to learn about the needs and assets of your target population. Consider conducting a small series of narrative case studies or using standardized assessment instruments.
- When you choose patients to interview, be sure to include those identified through population data as well as those identified by providers.
For more information
- Learn more about IHI's complex care efforts.
- Download the Three-Part Data Review worksheet.
- Access the HARMS-8 and the PAM Survey, standardized assessment instruments.
- Read about CareOregon’s experience conducting a Three-Part Data Review.
- Explore resources in the Playbook related to the key question, “Who are people with complex needs?”