Providing high-quality, timely care to complex patients—such as those with mental illness, disability, complex chronic conditions, or multiple conditions—is challenging for health care providers. These patients have unique needs that may span multiple health care providers and settings. Health care providers need timely, actionable information on how to best improve care for these complex patients.
High-performing accountable care organizations (ACOs) may use strategies, approaches, and processes to implement evidence-based care for patients with complex needs that other health care providers may find useful. At The Dartmouth Institute, we are studying ACOs to learn more about how they are effectively improving care for complex patients.
To learn how ACOs are caring for complex patients, researchers at The Dartmouth Institute will conduct interviews with clinical leaders at high-performing ACOs. Interviews with ACO leaders will help us learn the ACOs' overall strategy and approach to providing care for complex patients. We will then interview one or two primary care practices that are part of the ACO to learn how those strategies are being implemented on the ground. From these interviews, we hope to gain a better understanding of how ACOs identify complex patients, how they manage the needs of complex patients, if (and how) they implement team-based care, and how they manage any non-medical needs that complex patients may have.