Connected care, shared goals: Design whole-person care for complex patient populations

Decision to withdraw more than $11 billion In terms of public health funding, including support for drug use disorders and mental health programs, it is a clear reminder of how fragile safety nets in our country are. As Medicaid may also face severe cuts, the burden of care for people with high demand and high costs will be even worse on an already overstretched care system.

These patients often navigate behavioral and physical health status as well as social risk factors, and they already constitute a disproportionate proportion of health care expenditures. If we want to serve them effectively and effectively, we will no longer be able to afford decentralized care or data silos. More than ever, meaningful progress depends on shared accountability, cross-sectoral collaboration, and a relevance approach to recognizing complexity as rules, rather than exceptions.

When the safety net disperses

Despite the urgency, our system is still built around plot care and isolated data. As healthcare systems continue to shift to value-based care, stakeholders must take the next step: creating a consistent model of care not only financially but also clinically and operationally. This begins with a broader look at what data is and a shared commitment to converting it into timely, patient-centric actions.

Data continue to act as a lubricant for care coordination, but are often defined. Admission, discharge and transfer (ADT) feeds are useful, but they are only part of high-demand, high-cost patients. More comprehensive data inputs, such as discharge data, behavioral health indicators, prescription history, follow-up status, crisis event patterns and social determinants, can provide a richer and more precise understanding of patient needs and how best to address those needs. Without this insight, early intervention can become difficult and care remains dispersed.

Considering that people with potential behavioral health needs are 350% – 700% more costly for treatment than the general population. The cost of high-demand high-cost people is as high as 29 times higher than that of ordinary patients. Although 50% of behavioral health diagnoses occur in outpatient settings, many people go through emergency department (ED) or inpatient care cycles due to the lack of appropriate coordinated alternatives. Nearly 10-15% of ED and hospitalization visits list behavioral health as primary or secondary diagnosis.

A broader blueprint for complex care

Serving high demand groups with high costs means identifying risks before upgrading. This means treating real-time data as a retrospective performance tool, but as a catalyst for active participation. This may include conducting crisis events across state lines, using prescription monitoring inquiries to overlap drug marks immediately after a patient is discharged from the hospital or missed an appointment or deploying a care navigator. These critical moments often determine whether patients recover or re-enter the healthcare setting at a higher cost.

Best practices for participating in these populations include:

• Integrate behavioral health and primary care data to support whole-person health care.
• Embed real-time cross-departmental data directly into the nursing team workflow to support timely informed action.
• Authorize the navigator to identify and take the connection opportunities in the ED and outpatient settings and take action.
• Concentrate information throughout the care continuum, including recommendations, transitions, follow-ups and social needs.

Establishing this type of interconnected care model requires a transition from organizational independence to shared responsibility. This means that health programs, providers and community organizations must be consistent around the same goals, use the same common insights, and act on behalf of the same patient in a coordinated way. This advocacy of patients is particularly important for people with more difficulty reaching behavioral health that often cross clinical, social and crisis systems.

Design care centered around complexity rather than convenience

To make real progress, the system must stop treating behavioral health and complex care needs as outliers and begin designing around.

This means:

• Make care navigation a permanent part of a value-based infrastructure.
• Behavioral health HEDIS measures (such as FUH) (follow-up for mental illness after hospitalization), FUA (follow-up after alcohol consumption or other drug use after ED visits) and FUM (mature illness after ED visits) were used as key performance indicators.
• Prioritize participation metrics to track whether the system is meeting people.

Connected care is not just a model; it is a mindset. This highlights the need for rapid infrastructure changes now, not just to respond to crises, but to help prevent them.

With the changes in the landscape of the safety net and the increasing uncertainty of funds, the path forward is also obvious. By investing in highly coordinated, data-informed care and aligned health programs, where providers and communities invest around shared goals, we can build a system to meet individuals with complex care needs, support whole-person health programs and comprehensively enhance care. This moment requires bold action, but it also provides a rare opportunity to design a system that will ultimately suit everyone.

Photo: Nataliia Nesterenko, Getty Images

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