Most complex care programs use a team approach to provide multiple services to people with complex needs while also trying to control costs. While many programs invest new resources in care for patients, a well-designed team can help control costs by allowing medical providers to work to the top of their license and delegating non-medical tasks to other team members, such as community health workers or medical assistants.
The goal of this play is to help you develop and cost your care model.
- Discuss the root causes of high service utilization among the population you are enrolling in the program. Which needs are currently being met? Which needs might you need additional support to meet? What is the prevalence of needs in the population?
- Define which roles are best suited to meet the needs of patients. Ask, “Who is the best person to do this work?” Many teams include care managers, nurses, social workers, community health workers, and physicians.
- Describe team members’ roles in relationship to other members of the enhanced care team and to other health care providers, such as medical specialists. Think about where team members will be located, and how their location will affect team dynamics and availability to patients.
- Determine the ideal caseload for each team and team member. Try to strike a balance between managing costs and managing caseload size.
- Try making a list of the tasks that need to be done, and a list of all the team members who might be available to do the work. Then, mix and match. Challenge yourself to think, “Do I really need a medical professional to do that? Would a community health worker do it even better?”
- In addition to the core care team, you may consider staffing in these roles: behavioral health specialist, pharmacist, dietitian, and pain management specialist.
- While many complex care programs aim to reduce costs, it’s important not to try to cut costs by overloading team members with patients. Caseloads that are too large can lead to staff turnover and lower quality of care.
- Consider team members that may be outside your organization, working in community resources. Could you meet some patient needs through partnerships with other services, rather than providing them yourself?
For More Information
- Learn more about IHI's complex care efforts.
- For an in-depth discussion on staffing, review the Care Redesign Guide’s recommendations on developing and staffing a care model.
- View slides from the Cambridge Health Alliance about staffing a complex care management program.
- Learn more in these resources in the Playbook:
- To learn more about the community health worker role, please read "Diffusion of Community Health Workers Within Medicaid Managed Care: A Strategy to Address Social Determinants of Health."
- To learn more about the care manager role, please read "Care Management Plus: Strengthening Primary Care for Patients with Multiple Chronic Conditions."
- Learn how to effectively partner with community resources.
- Learn how to use a Three-Part Data Review to understand the root causes of high health care utilization among your patients.
This play was developed by the Institute for Healthcare Improvement (IHI) based on their work in the Better Health and Lower Costs for People with Complex Needs collaborative, which ran from 2014-2017.