Identifying Effective Strategies for Coordinating Health Care and Social Services for High-Need, High-Cost Patients

In addition to health care, people with multiple chronic conditions or other complex health problems often require a range of social services as well. To achieve optimal health and cost outcomes, all of these services must be delivered in a coordinated fashion. A logical place for this coordination to occur is at the community level. This project aims to identify strategies across U.S. communities that have reduced the need for institutional care, such as hospitalization, and controlled Medicare expenditures for these patients. Through site visits and interviews with hospital staff, social service providers, and others, the research team will identify tools and processes used to coordinate health and social services and methods for coordinating financing. Communities with successful strategies in place will be compared and contrasted with low-performing communities. The team also will explore coordination approaches for specific subpopulations, such as the frail elderly.