Patients with complex health needs often require a variety of different services, which warrants careful coordination from caregivers. Stakeholders discussed options to better care for these patients at the 2023 Oregon State of Reform Health Policy Conference.
Trey Sutten, co-founder and CEO of Siftwell Analytics, said he often thinks of individuals in the foster care system when discussing patients with complex needs.
“[With] the foster care population, oftentimes, you’ve got a very complex system of funding that needs to be braided together where incentives are misaligned,” Sutten said. “You’ve got money coming from the county, from the federal government, (and) from a payer. You’ve got a lot of different funding streams that need to be considered. Frankly, we have a responsibility to make some changes to drive better health for those kids.”
Albertina Kerr CEO Allison Stark said it is difficult to blend long-term services and supports like housing, residential services, and climate services with traditional and mental healthcare.
“Those things are funded in entirely different ways, but there (are) oftentimes a lot of intersections,” Stark said. “We have adults that have intellectual disabilities. But they might have a disability that requires licensed practicing nurses providing 24/7 support for them.”
Prior to moving to Oregon, Sutten was the CEO of a managed care organization (MCO) in North Carolina. It covered populations with diagnoses related to mental health, substance use disorders (SUDs), and intellectual development disabilities.
“A lot of times, care managers were assigned [to patients] based on historic measures or triggers. And oftentimes those triggers were articulated in a Medicaid contract; things like the number of ED (emergency department) visits in the last six months or year. And I always thought we could do a better job of that. It started to form my thinking about how we get folks assigned to the right individuals or provider types based on the supports and services they need.”
— Sutten
Various needs of patients with complex cases can oftentimes be overlooked, Stark said.
“We see these individuals coming into EDs that are trying to send them out to psychiatric facilities,” Stark said. “And you have psychiatric facilities saying, ‘What are this person’s other co-occurring diagnoses?’ And if it’s an intellectual disability, autism, or something like that, they’re like, ‘We don’t deal with anyone with an IQ lower than 70.’ And then where are they to go? A lot of times they end up in EDs, sitting there for a long time waiting for care.”
This can lead to patients with complex needs falling out of the system of care, Stark said.
“That raises an idea of specialization,” she said. “On one hand, we want a system of care that can serve everyone. But on the other hand, we know there are people who need more specialized services and supports.”
Artificial intelligence (AI) could help with complex care treatment. Siftwell uses AI to detect complex patterns of disease progression, the likelihood of a patient’s compliance with quality measures, and assistance in disenrolling members from a plan, Sutten said.
“I started a company that uses AI to kind of see the future around some of these individuals and their needs. It’s frustrating to me that we continually are surprised by a kid that ends up in an ED on a Friday afternoon. Parents drop them off and are unwilling to come pick them back up. We can know when things are progressing in a certain way, and how to get ahead of those things and introduce the right supports and services.”
— Sutten
Ned Mossman, director of social and community health at OCHIN, utilizes technology to help in providing complex care as well. He said OCHIN has conducted 2.3 million social needs screenings since the option was embedded in its electronic health records (EHRs).
“This isn’t new work for community health centers,” Mossman said. “But what’s new is we’re formalizing it and putting it in the EHR in a way that treats it like first-class structured data, being able to integrate it into decision support. AI can play a role in picking through all those chart notes where that data used to be buried. If you’re able to exchange that data, you can start to provide triggers for care teams to say, ‘I want to do a warm handoff; I want to navigate this patient to particular kinds of care they might need.’
It really opens up the door to being able to exchange that information with other organizations, particularly to help in that continuum of care. It’s not just the screening, it’s embedding it as data that has the same standing as traditional clinical data that’s really important.”
Caregivers can also pay more attention to practical details, like the aging of parents who have a child with complex needs, Sutten said.
“We know people don’t get younger, so parents of IDD (intellectual development disorder) children are getting older,” he said. “They eventually will need a different setting. They’ll eventually need a different set of supports and services. But a lot of times, myself included at the MCO I ran, we didn’t do that. We didn’t think about the age of parents for the IDD folks we were covering.”