Session 9: Care Integration for Patients with Complex Needs: The Challenges and Paths Forward

Health systems are often structured around institutions and organ systems, which is not ideal for people with multiple conditions who receive care from across the continuum on an ongoing basis. People with complex needs are a subset of the 5% of the population which account for over 50% of health system costs, without always meeting their needs. Primary care is helpful, but really, these patients need care that is coordinated across hospital, primary care and home care. Researchers and policymakers have been trying to understand this problem and generate solutions for the last 15 years, and while there has been some progress, we are still uncovering different facets of the problem, which are complex and require dynamic and multidisciplinary solutions. This panel described 9 different subgroups of people with complex needs that could be targeted as well as 5 subgroups of persistently high users of primary care. It followed with descriptions of promising projects that address these groups that are based in primary care and in acute care. It described a specific project at Trillium Health Partners in Ontario, which has used a learning health system approach to combine multiple programs into a coherent integrated whole to meet a wide range of patient needs.

Learning Objectives

1. Describe subgroups of people with complex needs and persistent high users of primary care.

2. Describe different programs that integrate care for people with complex needs.

3. Discuss how a learning health system approach can inform the design of new models of integrated care delivery within a region.

Panelists

Paul Ronksley, PhD
-Associate Professor, University of Calgary, Cumming School of Medicine, Department of Community Health Sciences
-Associate Scientific Director, O’Brien Institute for Public Health

Terence Tang, MD
-General Internal Medicine physician at Trillium Health Partners (THP)
-Clinician Scientist at the Institute for Better Health