Developing State-Level Programs for Care of Complex Populations

For the past 4 years, the National Governors Association Center (NGA Center) for Best Practices Health Division has been working with 10 states and Puerto Rico on state-level solutions to care for complex populations. Using lessons learned from that work, the NGA Center has released a road map to guide states in establishing their own complex care programs.

States implementing programs for complex care populations must target high-need, high-cost Medicaid enrollees who are high utilizers of the emergency department and other costly settings of care. The road map highlights the work in Alaska, Colorado, Connecticut, Kentucky, Michigan, New Mexico, Puerto Rico, Rhode Island, West Virginia, Wisconsin, and Wyoming.

“Effective complex care programs prioritize increased access to primary care, timely transitions from acute care settings, and a multi-disciplinary approach which prioritizes care coordination and includes pharmacy, behavioral health, and social support services in the community (such as housing, employment, and transportation),” according to the report.

The report includes 4 lessons learned:

• Alignment across state and local health reform initiatives allows for comprehensive and precise care delivery and payment strategy development.
• A data-driven approach is the cornerstone of successful, sustainable programs.
• The right people need to be at the table early and engaged in implementation.
• A care delivery and payment approach that incentivizes access to cost-effective interventions for the target populations needs to be developed.

Programs across the country that led the way for NGA Center’s program include the Camden Coalition of Healthcare Providers in New Jersey and Hennepin Health in Minnesota. The states that worked with the NGA Center targeted users of potentially preventable emergency department services and inpatient care and were able to successfully shift use to outpatient care, which improved health and saved millions of dollars, according to the report.

While the models in each state varied depending on the needs of the targeted population, there were some common elements, and NGA Center was able to identify 4 components to build the road map:

• Develop internal resources, build stakeholder partnerships, and conduct environmental scans
• Build a theory of the case, identify the target population, and design a way to track and evaluate the approach
• Develop and implement a delivery and payment model
• Track implementation, evaluate the program, and communicate the findings

States can use all parts of the road map or just portions of it as it applies to their situation in order to design a program.

“The road map is a tool to help states improve the health of their residents in a cost-effective manner given increasing budget constraints,” according to the report. “It serves as a step-by step guide to help states assess their capacity to create complex care programs, select evidence-based practices to maximize outcomes, implement effective targeting and evaluation strategies and consider lessons learned from early adopters.”

View the full report to see the programs in all 10 states and Puerto Rico.