Hospitals can make significant headway in reducing readmissions by addressing high-needs patients, according to a new National Academy of Medicine (NAM) special publication, which notes that nearly half of the nation’s spending on healthcare is driven by just 5% of patients.

Those patients can be identified long before discharge, making it possible to intervene early and reduce the likelihood of readmission, says Peter Long, PhD, chair of the planning committee for the NAM workshop series, and president and CEO of Blue Shield of California Foundation.

To improve health outcomes and curb healthcare spending, hospitals need to identify these high-needs patients and provide coordinated services through successful care models that link medical, behavioral, and community resources, the report says. The needs of this population extend beyond care for their physical ailments to social and behavioral services that often are central to their overall well-being, it says.

As a result, addressing clinical needs alone will not improve health outcomes or reduce healthcare costs, according to the NAM publication, which summarizes presentations, discussions, and scientific literature from a three-part workshop series. (The full report is available online at:

Common quality measures may not be enough to address high-needs patients, Long says.

“We think some of the quality measures in this are insufficient and misguided, so we’re calling for appropriate assessing of outcomes and rethinking of what could be better quality measures,” Long says. “We have to take into account the heterogeneous population and their functional status in addition to their access to healthcare. This is an area where hospitals have deep insight into what those measures should be or could be.”

The report examines the key characteristics of high-needs patients, the use of a patient categorization scheme as a tool to inform and target care, promising care models and attributes to better serve high-needs patients, and areas of opportunity to support the spread and scale of evidence-based programs.

Understanding the characteristics of high-needs patients is the first step in determining how to improve care, the report says, but consensus on those defining characteristics has been slow to evolve.

“Segmentation of the patient population and then applying different care models to those segments is a key concept, and some health systems are beginning to take that approach. That is a starting point that any hospital or health system could do today on their own,” Long says. “We gave some examples based on claims data, but we think health systems themselves have much better data and do their own segmentation based on a number of factors like utilization and functional status.”

NAM says three criteria could help define and identify this population: total accrued healthcare costs, intensity of care utilized for a given period of time, and functional limitations. Functional limitations include limitations in activities of daily living — such as dressing, bathing, self-feeding, and grooming — or limitations in instrumental activities of daily living that support an independent lifestyle — such as housework, shopping, managing money, taking medications, or using transportation.

Care Models Identified

Research indicates that high-needs individuals are disproportionately older, female, white, and less educated, the report notes. They also are more likely to be publicly insured, have fair-to-poor self-reported health, and be susceptible to lack of coordination within the healthcare system. Therefore, improving outcomes for this population requires assurance of attention to an individual’s functional, social, and behavioral needs — largely through social and community services, NAM recommends.

“Understanding how to care effectively for high-needs patients requires ascertainment of the key factors driving the needs for of each individual. Because this patient population is heterogeneous, those factors will differ for different segments of the population,” according to the report. “Therefore, the use of a practical taxonomy that helps group individuals by the care they most need, as well as when, how, and how often they might need it, can inform decisions about how to serve these patients more effectively.”

In the course of the meeting series that formed the basis of the report, a taxonomy working group identified for discussion the taxonomic elements that might help align high-needs patients with the care models that target their specific circumstances. While the success of even the best care model will depend on the particular needs and goals of the patient group a model intends to serve — which vary for different segments of high-needs patients — all successful care models aim to foster effectiveness across three domains: health and well-being, care utilization, and costs, the report notes. The planning committee identified 14 successful care models for high-needs patients and cross-referenced those to the segment(s) of the proposed taxonomy that could be served if health systems leaders match the needs of their patients to appropriate models within this menu of evidence-based approaches.

“A number of barriers currently prevent the spread or sustainability of successful care models, including the misalignment between financial incentives and the services necessary to care for high-needs patients, health system fragmentation, workforce training issues, and disparate data systems that cannot easily share needed information,” NAM says.

The publication discusses these barriers as well as strategies for addressing them. NAM identified the following opportunities for action and reform:

  • Refining the starter taxonomy based on real-world use and experience to facilitate the matching of individual need and functional capacity to specific care programs.
  • Integrating and coordinating the delivery of medical, social, and behavioral services to reduce the burdens on patients and caregivers.
  • Developing approaches for spreading and scaling successful programs and for training the workforce capable of making these models successful.
  • Promoting payment reform efforts that further incentivize the adoption of successful care models and the integration of medical and social services.
  • Establishing a small set of proven quality measures appropriate for assessing outcomes, including return on investment, and continuously improving programs for high-needs individuals.
  • Creating road maps and tools to help organizations adopt models of care suitable for their patient populations.

Find Key Drivers in Care Models

Long notes that while there are hundreds of models of care designed to address high-needs patients — and the NAM report highlights 14 of the most well-known — the models need more study before any can be determined the best, he says, and it may be that there is no single model to adopt. Even care models that have proven success with some institutions can be difficult for any one hospital to adopt exactly as outlined, he says. A better strategy might be to identify what makes any model work and apply those concepts as appropriate in the hospital, which may not be exactly the way they were applied elsewhere, he says.

“Deconstruct that model into its component parts and you might find that it’s really about improved communication — data sharing among different players, for instance,” Long says. “Those elements can be applied without necessarily taking on the care model lock, stock, and barrel, which sometimes doesn’t work because hospitals and health systems have unique characteristics.”

Segmentation of a health system’s patient population and developing a high-needs care model will require significant new and different data collection, as well as data flow, Long says.

“We don’t underestimate the magnitude of what we’re talking about for hospitals. When we say, ‘you have to incorporate behavioral health and social risk factors,’ we know that means incorporating a lot of new players, with different data and different systems,” Long says. “We think data collection is going to be a challenge.”

The move toward value-based care should be an impetus for improving the care of high-needs patients, Long says.

“As a hospital moves toward value-based care, they will need to improve the care of high-needs populations because they get a sum of money to produce an outcome. It reinforces the need for segmentation and providing a care model tailored to the needs of these patients,” he says. “Value-based care is an accelerant to all of these care models.”