Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers

Posted by Sharyn Rognrust, 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.

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