Beyond the Emergency Department: How We Can Improve Care for Patients With Complex Needs

Beyond the Emergency Department: How We Can Improve Care for Patients With Complex Needs

As a physician, I have struggled with the question of how best to care for patients with complex needs since my early days of working in a hospital emergency department. Back then, my colleagues and I routinely encountered people in crisis who were battling medical, behavioral, and social difficulties all at once. And I realized over time that while we did our best to address their clinical problems, the issues they faced at home or in their communities were often what led them to the ED.

In recent years, my colleagues and I collectively have come to the realization that our patients — and others facing similar challenges — have, in many ways, been failed by society. Researchers have uncovered patterns of unstable, traumatic childhoods among patients with complex needs. They've also learned that many of these patients felt disrespected by the hospitals and clinicians who cared for them, which often resulted in patients skipping their medications or missing needed appointments. All too often, patients with complex needs are seen as statistics — just another person with diabetes or heart failure — when what those patients desperately want and need is to be acknowledged as individuals.

While the social implications of how we fail to fully care for these patients are deeply troubling, the economic cost is equally stark. We know that while people with complex needs represent only about 5 percent of the U.S. population, they represent about half of all healthcare spending.

Today, we know that addressing the issues of patients with complex needs can't be done through clinical or technological solutions alone. For patients with diabetes, for example, that might mean figuring out whether they have a place to exercise, a market nearby where they can get fresh fruits and vegetables, or even transportation to and from their doctor's office. The good news is that the sorts of promising approaches needed to spur change nationally have begun sprouting up in every corner of the United States. Some of these models address the trauma that many patients have faced head on. Other initiatives have attempted to replicate the pioneering work of the Camden Coalition of Healthcare Providers, which closely coordinates medical care and social services for patients with multiple hospital admissions and a mix of clinical and social needs.

Of course, the scale of the challenge means that no one institution will be able to get there alone. If we're going to transform how we care for patients with complex needs nationally, we will have to find new ways to work together — and not just in the areas of health care or public health, but across our communities. That spirit of collaboration is evidenced by the new National Center for Complex Health and Social Needs, which is led by the Camden Coalition. We envision the center as a place where many different innovators — including clinicians, social service providers, researchers, public health leads, policy makers, consumer advocates, and others — can share ideas or new research and ultimately identify and spread new, evidence-based approaches to treating patients with complex needs.

We're also working closely with four other funders — the Commonwealth Fund, the John A. Hartford Foundation, the Peterson Center on Healthcare and The SCAN Foundation — to develop a "Playbook" of case studies and resources that providers, insurers, policy makers, and others can use to better design care for patients with complex needs. Before, each of our philanthropies had been working on different pieces of this puzzle, but we realized that, by working together, we could have a far greater impact on how we care for patients with complex needs than we could individually.

As I discovered in my early days in the ED, the time we spend clinically caring for patients with complex needs only allows us a glimpse into their lives. Ultimately, the only way we can give these patients the care they need and deserve is by understanding and embracing the fact that they are unique individuals who might need access to food, transportation, or housing as urgently as they need medical care. Together, we should use this insight to help all people with complex needs lead the happier, healthier lives they deserve and move their communities — and the nation — closer to achieving a Culture of Health.

John Lumpkin, MD, is a senior vice president with the Robert Wood Johnson Foundation.