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What Is Complex Care?

The U.S. health care system is often fragmented and uncoordinated, leading to inefficient and unnecessarily expensive care. For people whose health is closely tied to a mix of significant medical, behavioral health, and social challenges, this ineffectiveness can have serious consequences.

Complex care strives for highly coordinated, person-centered approaches that enable people with an array of health and social needs to achieve their goals for better health and well-being.

Who are adults with complex needs?

Adults with complex needs are a subset of the U.S. population with a substantial mix of medical, behavioral health, and social needs. This diverse population often has higher rates of hospitalization and emergency department use compared with the broader population. Yet, despite high service use, people with complex needs often experience worsening outcomes.

The following population subsets further define adults with complex needs by age, health condition, and functional status. While these distinctions can be helpful, the care needs within each of these subpopulations vary considerably, and many people fall under more than one of these categories. In addition, unmet social needs are common among individuals in all five of these groups.

Why rethink care for this population?

Adults with complex needs encounter a wide range of health and social service systems that often do not speak to one another — such as physical health, behavioral health, long-term services and supports, and social services. Complex care seeks to cut across these siloes, promoting new, integrated systems of services and supports that can help improve individuals' health and well-being. This integration may also help reduce the costs of avoidable care that commonly result from an otherwise uncoordinated system.

The Playbook identifies and amplifies evidence and promising practices with a focus on complex care interventions in various settings — including acute, primary, and transitional care, as well as behavioral health, long-term care, and serious illness and palliative care.

What are the features of complex care?

The complex care field is continuously evolving to improve care for the nation’s highest-need populations. At their core, complex care interventions coordinate care across settings, services, and sectors to facilitate access and minimize duplication. As we continue to learn about what works to promote high-quality complex care, these care models commonly work to:

What is the complex care business case?

A relatively small number of people account for a disproportionate share of U.S. health care costs — with behavioral health challenges and unmet social needs significantly contributing to health care costs and poor outcomes. Complex care seeks to achieve long-term quality or cost goals by supporting a “whole person” approach.

The Playbook identifies approaches to care that demonstrate proven or promising results in reducing avoidable health care utilization and cost while improving health. This includes value-based payment approaches that reward health care quality over volume. 

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What evidence supports complex care?

A wide range of health care stakeholders across the nation — from large health care organizations to community-level providers to state payers — are documenting successful approaches to serving people with the most complex needs. These complex care interventions can inform other organizations in designing or implementing new programs and practices or enhancing existing ones.

The Playbook is a growing library of resources aimed at advancing what works in complex care among several key stakeholders — including state and health plan payers, health care systems and providers, and policymakers.
 

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