The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

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Managing High-Needs Patients can Help Improve Outcomes at Michigan Hospitals

Abeer Yassine

Abeer is the MVC Hospital Engagement Associate

Only about 5% of patients are considered high-need, yet these patients constitute nearly 50% of total healthcare costs. High-need patients typically have more complex diagnoses and significant barriers to accessing healthcare that impacts the self-management of their condition(s) outside of the hospital. In a recent, pre-publication report, Effective Care for High-Need Patients, the National Academy of Medicine (NAM) outlines various characteristics of high-need patients, patient taxonomy models, along with care models. This report is a compilation of feedback from relevant workshops, presentations, discussions, and literature and stresses the importance of identifying and managing care delivery to high-need patient populations.

High-Need Patients Characteristics

To better create targeted initiatives in a hospital setting for high-need patients, there needs to be better identification of characteristics using data. Although there is not one, specific definition of “high-need patients”; functional limitations, complexity of care/disease, and health care costs are all characteristics that can be used to identify and analyze these patient populations. These characteristics not only impact the care that is delivered within the clinical setting, but also the ability for that patient to self-manage their health outside of the hospital.

High-Need Patient Taxonomies

NAM reviewed two patient taxonomy models in use by the Harvard T.H. Chan School of Public Health and The Commonwealth Fund to better segment patients for improved identification of high-need populations. Using a taxonomy model can guide health systems to more suitable integration of behavioral, social, and functional characteristics in the patient care plan outside of the clinical setting. What is unique about the taxonomy developed by NAM is that it builds upon clinical and medical characteristics to identify behavioral health and social factors that affect care delivery decisions. More detail about this starter taxonomy and a conceptual model can be found here.

Successful Care Models for High-Need Patients

This NAM report also uncovered common characteristics among care models that are successful in managing high-need patient populations. The report mentions that successful care models typically expand upon domains related to health and well-being, care utilization, and costs. Furthermore, these care models include details on dimensions related to service setting focus, care attributes, delivery features, and organizational culture. By targeting a specific high-need patient population (ex: age group), health systems are better able to create care models and initiatives geared towards improved, more integrated care delivery. The report also outlines an analytic framework that helped NAM identify successful care models for high-need patients.

The MVC Coordinating Center can help member hospitals identify domains and care utilization of high-need patients.  If you are interested in identifying these populations within your hospital, please reach out to Deby ( or Abeer (

Interested in learning more about optimizing care delivery for high-need patient populations? More information and a copy of Effective Care for High-Need Patients can be found below:

Adding a pharmacist to the care team helps reduce readmissions

Abeer Yassine

Abeer is the MVC Hospital Engagement Associate

Coordination of care has been shown to be extremely beneficial to patient care and many policy efforts have taken aim to engage the multitude of different health care providers.  Coordination among health care providers is beneficial not only to patient care, but also to optimizing resources and costs. Pharmacists are one member of the health care system that may not be used to their full potential, as the coordination between clinicians and pharmacists can help improve patient care through medication reconciliation, patient education, discharge planning, and reducing readmissions due to medication errors.

In an article published in The American Journal of Managed Care, post-discharge services provided by pharmacists were observed to study the impact on reducing hospital readmissions. A sample of high risk individuals enrolled in a managed Medicaid plan in California were observed thirty days’ post discharge. Pharmacists worked with outpatient clinicians on different services, such as patient education, discharge planning, and appointment transport arrangements to address medication-related barriers or other problems among patients. As a result of these transition of care services, there was a 25% lower risk of readmission compared to patients receiving typical care. Moreover, this transition of care pharmacy program significantly reduced 30 day readmissions at Kern Health Systems by 28%. More information on this study and methods used can be found here:

To emphasize the importance of care coordination, the Michigan Pharmacists Association (MPA) and MPA Public Affairs committee have developed a booklet that outlines several care areas where pharmacists can participate alongside other health care providers to improve the patient experience and outcomes.  A myriad of clinical areas are outlined in this booklet, along with information on studies performed to validate that collaboration along different service lines can be beneficial to patient care.  The booklet can be found here:

The addition of pharmacists as a member of the health care team and utilization of their expertise, especially concerning proper medication usage, can have a significant impact for any health care facility.

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