Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers, Category: Health Planning & Design,
Health care costs are heavily concentrated among people with multiple health problems. Often, these are older adults living with frailty, advanced illness, or other complex conditions
-Make care coordination a high priority.
-Identify patients in greatest need of proactive, coordinated care.
-Train more primary care physicians and geriatricians.
-Facilitate communication between providers—for example, through clinical record integration.
-Engage patients in decisions about their care.
-Provide better support for caregivers.
-Redesign funding mechanisms to meet patients’ needs.
-Integrate health and social services, and physical and mental health care.
-Engage clinicians in change and train and support clinical leaders.
-Learn from experience and scale up successful projects.