The Commonwealth Fund has a large body of work regarding the population of adult patients referred to as “high need, high cost” (http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/care-high-need-high-cost-patients). These are patients with multiple chronic health problems compounded by social problems. We know who these patients are and what models of care work.
We also know the medical and social complexity of these patients increases the likelihood of negative outcomes. These social problems include poverty, limited access to health care, low (health) literacy, and limited social support. We also know that care for this population is further complicated by a health care system NOT designed to address social needs. Health care providers often feel unprepared to care for the level of complex social care required by these patients (http://www.commonwealthfund.org/publications/in-the-literature/2015/dec/primary-care-physicians-in-ten-countries).
This is a great opportunity for primary care nurse practitioners whose unique combination of nursing and medical skills makes them particularly qualified and comfortable working with “high need, high costs” patients. We are well positioned to implement and evaluate innovative nurse-led practice models that either replace or augment traditional primary care. The Morehead Center for Nursing Practice team has designed a practice model that will offer complex care services to primary care practices with high need, high cost patients. Our inter-professional, team-based program is called C3 (Community, Complexity and Coordination). We plan to implement this program with willing partners across the state. If working with the C3 model interests you or you would like more information please contact me (email@example.com).