Identifying and Coordinating Care for Complex Patients

Findings from the Leading Edge of Analytics and Health Information Technology

by Robert S. Rudin, Courtney A. Gidengil, Zachary Predmore, Eric C. Schneider, James Sorace, Rachel Hornstein

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In the United States, a relatively small proportion of complex patients — defined as having multiple comorbidities, high risk for poor outcomes, and high cost — incur most of the nation's health care costs. Improved care coordination and management of complex patients could reduce costs while increasing quality of care. However, care coordination efforts face multiple challenges, such as segmenting populations of complex patients to better match their needs with the design of specific interventions, understanding how to reduce spending, and integrating care coordination programs into providers' care delivery processes. Innovative uses of analytics and health information technology (HIT) may address these challenges. Rudin and colleagues at RAND completed a literature review and held discussions with subject matter experts, reaching the conclusion that analytics and HIT are being used in innovative ways to coordinate care for complex patients but that the capabilities are limited, evidence of their effectiveness is lacking, and challenges are substantial, and important foundational work is still needed.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Results

  • Chapter Three

    Conclusions

  • Appendix A

    Details of the Literature Review

This work was funded by the Office of the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services and conducted by RAND Health.

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