THE LEARNING HEALTH SYSTEM SERIES

1 THE LEARNING HEALTH SYSTEM SERIESEFFECTIVE CAREFOR HIGH-NEED PATIENTSOPPORTUNITIES FOR IMPROVING OUTCOMES, VALUE, AND HEALTHP eter Long, Melinda Abrams, Arnold Milstein, Gerald Anderson, Katherine Lewis Apton, Maria Lund Dahlberg, and Danielle Whicher, EditorsWASHINGTON, DC ACADEMY OF MEDICINE 500 FIFTH STREET, NW WASHINGTON, DC 20001 NOTICE: This publication has undergone peer review according to procedures established by the National Academy of Medicine (NAM). Publication by the NAM signifies that it is the product of a carefully considered process and is a useful contribution worthy of public attention, but does not represent formal endorsement of conclusions and recommendations by the NAM. The views presented in this publication are those of individual authors and do not represent formal consensus positions of the authors organizations; the NAM; or the National Academies of Sciences, Engineering, and for this activity was provided by the Peterson Center on Healthcare, which is dedicated to identifying proven solutions that improve care quality, lower costs, and accelerate the adoption of these solutions on a national of Congress Cataloging-in-Publication DataNames: Long, Peter (Peter V.)

2 , editor. | National Academy of Medicine ( ), publisher. | Leadership Consortium for a Value & Science-Driven HEALTH SYSTEM , issuing body. | Models of Care for High-Need Patients (Workshop) (2015-2016 : Washington, )Title: Effective care for high-need patients : opportunities for improving outcomes, value, and HEALTH / Peter Long, Melinda Abrams, Arnold Milstein, Gerald Anderson, Katherine Lewis Apton, Maria Lund Dahlberg, and Danielle Whicher, editors ; Leadership Consortium for a Value & Science-Driven HEALTH : Washington, DC : National Academy Of Medicine, [2017] | Report on issues discussed over the course of 3 public workshops held between July 2015 and October 2016 at the National Academy of Medicine, Washington, DC. | Includes bibliographical : LCCN 2017041343 (print) | LCCN 2017042253 (ebook) | ISBN 9781947103078 (Ebook) | ISBN 9781947103061 (pbk.)

3 Subjects: | MESH: HEALTH Services Needs and Demand | HEALTH Services--utilization | Delivery of HEALTH Care--utilization | Delivery of HEALTH Care--economics | Patient Care Management--economics | United States | CongressesClassification: LCC RA425 (ebook) | LCC RA425 (print) | NLM W 84 AA1 | DDC record available at 2017 by the National Academy of Sciences. All rights in the United States of citation: Long, P., M. Abrams, A. Milstein, G. Anderson, K. Lewis Apton, M. Lund Dahlberg, and D. Whicher, Editors. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and HEALTH . Washington, DC: National Academy of Medicine. Knowing is not enough; we must is not enough; we must do. Goeth eLEADERSHIPINNOVATIONIMPACTfor a healthier futurevABOUT THE NATIONAL ACADEMY OF MEDICINEThe National Academy of Medicine is one of three academies constituting the National Academies of Sciences, Engineering, and Medicine (the National Academies).

4 The National Academies provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institu-tion to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineer-ing to advising the nation.

5 Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on issues of HEALTH , medical care, and biomedical science and technology. Members are elected by their peers for distinguished contributions to medicine and HEALTH . Dr. Victor J. Dzau is more about the National Academy of Medicine at COMMITTEE FOR THE WORKSHOP SERIES ON MODELS OF CARE FOR HIGH-NEED PATIENTSPETER V. LONG (Chair), President and Chief Executive Officer, Blue Shield of California FoundationMELINDA K. ABRAMS, Vice President, Delivery SYSTEM Reform, The Commonwealth FundGERARD F.

6 ANDERSON, Director, Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public HealthTIM ENGELHARDT, Director, Federal Coordinated HEALTH Care Office, Centers for Medicare & Medicaid ServicesJOSE FIGUEROA, Instructor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women s HospitalKATHERINE HAYES, Director, HEALTH Policy, Bipartisan Policy CenterFREDERICK ISASI, Executive Director, Families USA; former HEALTH Division Director, National Governors AssociationASHISH K. JHA, K. T. Li Professor of International HEALTH & HEALTH Policy, Director, Harvard Global HEALTH Institute, Harvard Chan School of Public HealthDAVID MEYERS, Chief Medical Officer, Agency for Healthcare Research and QualityARNOLD S. MILSTEIN, Professor of Medicine, Director, Clinical Excellence Research Center, Center for Advanced Study in the Behavioral Sciences; Stanford UniversityDIANE STEWART, Senior Director, Pacific Business Group on HealthSANDRA WILKNISS, Program Director, HEALTH Division, National Governors Associationviii | Effective Care for High-Need PatientsNAM StaffDevelopment of this publication was facilitated by contributions of the follow-ing NAM staff, under the guidance of Michael McGinnis, NAM Leonard D.

7 Schaeffer Executive Officer and Executive Director of the Leadership Consortium for a Value & Science-Driven HEALTH SYSTEM :KATHERINE LEWIS APTON, Program Officer, National Academy of Medicine (until January 2017)MARIA LUND DAHLBERG, Associate Program Officer, National Academies of Sciences, Engineering, and Medicine (until April 2017)ELIZABETH MALPHRUS, Associate Program Officer, National Academy of Medicine (until June 2015)DANIELLE WHICHER, Senior Program Officer, National Academy of MedicineMINA BAKHTIAR, Senior Program Assistant, National Academy of Medicine (until May 2016)GWEN HUGHES, Senior Program Assistant, National Academy of MedicineCARRIE WOLF, Senior Program Assistant, National Academy of Medicine (until March 2016)BROOKE KEANE, Intern, National Academy of Medicine (until August 2017)

8 DANIEL BEARSS, Senior Librarian, National Academies of Sciences, Engineering, and MedicineLAURA DESTEFANO, Director of Communications, National Academy of MedicineKYRA E. CAPPELUCCI, Communications Specialist, National Academy of MedicineMOL LY DOY L E, Communications Specialist, National Academy of MedicineConsultantJOE ALPER, Science Writer and RapporteurixTAXONOMY WORKGROUPMELINDA K. ABRAMS, Vice President, Delivery SYSTEM Reform, The Commonwealth FundGERARD F. ANDERSON, Director, Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public HealthMELINDA J. BEEUWKES BUNTIN, Chair, Department of HEALTH Policy, Vanderbilt University School of MedicineDAVE A. CHOKSHI, Assistant Vice President, New York City HEALTH and Hospitals CorporationH ENRY CLAYPOOL, Policy Director, Community Living Policy Center, University of California San FranciscoDAVID A.

9 DORR, Professor & Vice Chair, Medical Informatics, Department of Medical Informatics & Clinical Epidemiology, Oregon HEALTH & Science UniversityJOSE FIGUEROA, Instructor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women s HospitalASHISH K. JHA, Li Professor of International HEALTH and HEALTH Policy, Director, Harvard Global HEALTH Institute, Harvard Chan School of Public HealthDAVID LABBY, Founding Chief Medical Officer & HEALTH Strategy Adviser, HEALTH Share of OregonPRABHJOT SINGH, Director, Arnhold Institute for Global HEALTH , Mount Sinai HEALTH SystemPOLICY WORKGROUPGERARD F. ANDERSON, Director, Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public HealthTIM ENGELHARDT, Director, Federal Coordinated HEALTH Care Office, Centers for Medicare & Medicaid ServicesKATHERINE HAYES, Director, HEALTH Policy, Bipartisan Policy CenterSANDRA WILKNISS, Program Director, HEALTH Division, National Governors AssociationxiREVIEWERSThis special publication has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with review procedures established by the NAM.

10 We wish to thank the following individuals for their review of this publication:BRUCE CHERNOF, The SCAN FoundationBRUCE HANSON, First Lutheran ChurchJULIAN HARRIS, CignaGAIL WILENSKY, Project HOPEA lthough the reviewers listed above have provided many construc-tive comments and suggestions, they were not asked to endorse the content of this publication, nor did they see the final draft before it was published. Review of this publication was overseen by Danielle Whicher, senior pro-gram officer, NAM; Gwen Hughes, senior program assistant, NAM; and Michael McGinnis, Leonard D. Schaeffer Executive Officer, NAM. Responsibility for the final content of this publication rests entirely with the authors and the E FAC EThe National Academy of Medicine s Leadership Consortium for a Value & Science-Driven HEALTH SYSTEM provides a trusted venue for national lead-ers in HEALTH and HEALTH care to work cooperatively toward effective, innovative care that consistently adds value to patients and society.