Care Redesign Guide: Better Health and Lower Costs for People with Complex Needs

Catherine Craig
Cory Sevin
Aricca Van Citters
Technical Assistance Tool

This resource offers a structured improvement process for redesigning care for people with complex needs and high health care costs.

  • This guide harvests the experience of over 200 organizations who have worked with the Institute for Healthcare Improvement (IHI) in the Triple Aim Improvement Community and the Better Health and Lower Costs for Patients with Complex Needs Collaborative.
  • This resource includes six modules to drive care redesign for people with complex needs and high health care costs: choosing your population; identifying individuals; revolutionizing patient engagement; developing a care model; strengthening partnerships; and executing successful changes.
  • Each module describes a summary of effective implementation methods as well as core recommendations, lessons from the field, and links to resources from IHI and national exemplars. 
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Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • How do I choose a population of focus and learn more about their needs and assets?
  • How do I find individual patients who are a good fit for my program?
  • How do I effectively engage my population of focus?
  • How do I design a care model that is effective and sustainable in my setting?
  • How do I develop effective internal and external partnerships to meet the needs and build on the assets of my population?
  • How do I continue to improve and scale our enhanced care model?
Level of Evidence
Expert Opinion
What does this mean?