WIHI on identifying patients with complex needs

Madge Kaplan writes:

The next WIHI broadcast — When Everyone Knows Your Name: Identifying Patients with Complex Needs — will take place on Thursday, January 29, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Catherine Craig, MPA, MSW, Independent Consultant; Faculty, Better Health and Lower Costs for Patients with Complex Needs, IHI
• Matt Stiefel, MPA, MS, Senior Director, Center for Population Health Care Management Institute, Kaiser Permanente
• Eleni Carr, MBA, MSW, Senior Director of Care Integration, Cambridge Health Alliance
• Kathy Weiner, MHSA, Regional Executive Director, Medicare, Kaiser Permanente

A relatively small percentage of the US population accounts for the largest share of health care costs. Everyone knows who we're talking about, right? Well, not exactly. Broad assumptions (e.g., high utilizers of the emergency department) and sweeping generalizations often substitute for more robust inquiries and analysis designed to better pinpoint a hospital or clinic's patients with unmanaged, complex health problems. And, without this specificity, it's hard to know who will benefit most from additional supports and interventions.

This is among the reasons why an IHI Collaborative involving some 45 health care organizations has been focusing like a laser this past year on developing reliable ways to identify patients with complex needs. It's hard but necessary work, and we're going to explore what it entails on the Jan. 29 WIHI: When Everyone Knows Your Name: Identifying Patients with Complex Needs.

We’ve pulled together a terrific panel for the program. Catherine Craig will set some context and background for adopting more sophisticated methods to identify patients with complex issues and needs. The Cambridge Health Alliance’s Eleni Carr will walk us through the tools and systems her safety net organization is now using to enroll patients in a complex care management program. Matt Stiefel and Kathy Weiner from Kaiser Permanente (KP) have been hard at work developing and refining tools to further segment populations with complex needs which, in turn, leads to better predictive models. This helps KP plan for the services and costs necessary to meet patient needs.

The January 29 WIHI will be followed by another in 2015 focused on new care designs and better outcomes for patients with complex needs. We look forward to your comments and participation!

You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.