Interventions for Patients with Complex Medical and Social Needs
Abstract
Patients with multiple chronic conditions and social needs represent a small percentage of the population but have a disproportionate impact on healthcare costs and utilization. Organizations around the United States have created programs, often referred to as complex care interventions, to improve the health and well-being of such patients and reduce avoidable hospital and emergency department use. In this tutorial, we focus on two emerging themes in the field: (1) identifying clinically meaningful subgroups in complex care populations through unsupervised learning methods and (2) describing the key operational features of interventions with an emphasis on staffing needs and the impact on patient outcomes. The material presented in this tutorial draws on the research of the Healthcare Operations Research Laboratory at the University of Massachusetts, Amherst, and its collaborating partners. To illustrate these themes and contextualize the details of complex care delivery, we use a range of patient-level examples, visualizations, descriptive summaries, case studies, and results from the clinical literature.
Funding: This research was funded by the U.S. National Science Foundation [Grants NSF CMMI 1254519 and NSF CMMI 2212237]. The views expressed in this paper are of the authors and not of the National Science Foundation.
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