NYAPRS Note: A very thoughtful piece by two experts in the area of improving care for people with extensive health, behavioral health and social needs who believe that “over the past decade, the complex care field has become far more sophisticated in delivering better, more tailored care” and that “the past year has driven home the imperative to raise the bar for how we care for our most at-risk individuals.
Envisioning The Future Of Complex Care
By Allison Hamblin and Kedar Mate Health Affairs February 19, 2021
The past 10 years have seen major growth in the field of complex care—a field that aims to better coordinate care and improve outcomes for individuals with complex health and social needs. With a growing evidence base of best practices, and the emergence of supportive payment models following the passage of the Affordable Care Act, the number of health care systems and health plans engaged in complex care has expanded dramatically. More recently, the field has seen its first randomized controlled trials; has begun to organize itself around a standardized set of core competencies; and is starting to fill gaps in quality measurement to assess more accurately individual- and program-level impacts.
So, what is the future of complex care? Understanding how to fortify the nation’s complex care infrastructure can help inform the priorities of the Biden-Harris administration and the Department of Health and Human Services. As the leaders of two organizations involved in collaborative efforts to advance the field of complex care, including the Better Care Playbook as well as the 2017 development of the Blueprint for Complex Care alongside the National Center for Complex Health and Social Needs, we came together to forecast what the next four years might look like and identify opportunities to build a stronger and more effective field of complex care going forward.
Here are our top 10 predictions for the future of complex care in the US:
1. The science behind complex care will flourish. One effect of COVID-19 is that the pace of learning has accelerated exponentially. This will have implications for every scientific field in the years ahead, including the science underpinning complex care. Accordingly, over the next five years, the evidence behind complex care interventions will get progressively stronger and clearer, building on recent randomized control trials. This growth will be driven through more research around complex care models and participation in practice-based research networks, as well as by further refinements and changes to complex care research methods. In turn, the field will be better positioned to capture data about interventions, outcomes, and populations served, and it will be possible to measure more of what matters to patients and providers. Research will not only uncover answers to what works but will also help reveal how to get best practices into the right hands at every possible turn.
2. The field will embrace nuance about which interventions work and for whom. To date, complex care has been a relatively blunt instrument, focusing primarily on care management and care coordination with minimal tailoring of intervention approaches. However, as recent studies have shown, these approaches do not work for some patients with complex health and social needs. As the field continues to mature, it will increasingly employ more diverse care pathways—some within health care and some outside it—for different population subsets. These pathways may focus on mental health or substance use disorder treatment, supportive housing, or trauma treatment that gets at underlying root causes of adversity. Rather than investing in a “care management for all” approach, the health system and partners in other sectors can deploy care management resources for some, while also strengthening other service capacities that may be underdeveloped at the community level.
3. Social determinants of health will go mainstream. Complex care programs, and health care organizations more broadly, are increasingly looking to address health-related social needs—a focus that will become more pervasive in years ahead. Health care systems will be more likely to invest in social services, especially housing and food, as the data get clearer about the relationship between providing these services and improving health outcomes. In the near term, we are likely to see a quality measure set emerge for social determinants of health, paired with improved opportunities to pay for health system interventions that address upstream and social determinants of health. As health care takes on this broader role, it should avoid trying to do too much on its own and instead seek cross-sector or community-based partnerships, while also avoiding the temptation to focus on the effects (for example, hunger) versus the root causes (for example, better employment or education).
4. The complex care pipeline will be disrupted. Complex care programs address the cumulative downstream effects of many missed opportunities to intervene over a life-course. Unless we look upstream, there will always be a pipeline of patients flowing into the complex care pathway. The best way to avoid the need for complex care down the road is to start identifying risk and building resilience through investments in early childhood. This shift begins with increased understanding across health care of the impacts of adverse childhood experiences and a move to embrace family-centered and multigenerational approaches to care. As the health care system increasingly acknowledges the connections between child well-being and health later in life, it will value the return on investments in early childhood—and, more importantly, give children a better head start in life.
5. Health care organizations will get smarter about identifying risk. As health care stakeholders increasingly embrace a population health approach, we will be able to identify risk for poor health outcomes and high health care costs and use earlier on. By incorporating a broader array of health and social data into risk algorithms, and using machine learning and other segmentation strategies to better understand risk groupings and trajectories, we will be able to identify more efficient and effective opportunities for intervention. Rather than waiting until someone shows up as a high utilizer of health care resources, we will identify “rising risk” and deploy interventions—many of which may address social determinants of health—that will prevent individuals from ever requiring complex care programs to begin with.
6. Technology will drive new modes of care delivery. There are ample opportunities to embrace the power of technology to improve care delivery. The COVID-19 pandemic spawned a broad array of regulatory and payment flexibilities to support the use of telehealth. As a result, patients, families, and clinicians have benefited from expanded access to alternative modalities of care. On the heels of this accelerated adoption of virtual care delivery, the format will continue to grow, creating more options for patients to engage in needed care according to their preferences and unique circumstances. The health care system will benefit from higher engagement rates and, with accountability for outcomes, will be motivated to invest in deploying effective technologies to lower-resourced communities to ensure that the benefits are accessible to all patients, regardless of income.
7. Primary care will become more comprehensive and more complex. Alongside improvements in technology, “convenience care” at retail clinic and urgent care locations will expand in both volume and scope—providing not only flu shots and vaccines, but also more basic primary care. In turn, traditional primary care will become increasingly specialized with a more concentrated population of sicker and more challenging patients, necessitating more comprehensive team-based care. Primary care, as we know it today, will transition to become more of a complex service with a focus on behavioral health integration, social needs coordination, and substance use disorders. This change in the primary care model will require more care coordination, data integration, and likely new technology to support and “super charge” primary care to enable more intensive follow up and referral connections.
8. Insurers will pay for complex care differently. As the health care sector continues its evolution away from fee-for-service reimbursement and toward value-based payment, the field is beginning to see a transition to global budgeting and total cost of care models across payers. This shift will increasingly link reimbursement to better outcomes and reduce the barriers to providing the right care at the right setting at the right time. For complex care programs, these new payment models will likely produce wide-scale experimentation with new care team designs, workforce strategies, and partnerships across sectors to better serve complex-need populations.
9. Accountability for equity will become a new norm. After events of the past year—inequities laid bare by COVID-19 and racial unrest nationwide—many health care institutions are drilling down on righting the wrongs of structural racism and systemic oppression. As a start, health care providers can track and tie dollars, at least in part, to outcomes that are stratified by race, ethnicity, and language. With data in hand, it will be possible to build quality measures focused on reducing disparities and begin to pay differently to address inequities systematically. Of course, that is just a start. The health care system has much more work to do to eliminate bias in its workforce and racism in its systems but adding accountability for equity going forward will begin to forge a foundation for a more just care system.
10. Public health will be viewed as an essential investment. Finally, among the many lessons of the pandemic, it is imperative that we commit to avoiding the heavy toll that comes from an underfunded public health infrastructure when future crises inevitably strike. The US must direct more public resources into primary prevention and health promotion, and encourage closer connections between our public health and health care systems. The COVID-19 vaccine distribution efforts will provide a critical opportunity to strengthen these connections and to build toward a future that more effectively marries the strengths that each sector can contribute to protecting and improving our nation’s health. As the pandemic has demonstrated, the health of our society is only as strong as the conditions that exist, and the efforts we make, for the most vulnerable among us.
Over the past decade, the complex care field has become far more sophisticated in delivering better, more tailored care for individuals with complex health and social needs. The past year has driven home the imperative to raise the bar for how we care for our highest-risk patients and populations. And with new tools for care delivery, more flexible and accountable payment models, and increased readiness for a rigorous research agenda, the field is now poised for an accelerated pace of learning and development in the years ahead. With the energy and ideas of a new federal administration, there are tremendous opportunities to continue this momentum. To the extent the above forecast plays out, we can improve outcomes for those served by complex care programs, and completely avoid the need for complex care for many others.