States pursuing the three-part aim of improved health, high quality care, and reduced costs often start with programs for complex care populations. These programs target high-need, high-cost Medicaid enrollees who are the most frequent users of costly sites of care, such as emergency departments and inpatient settings, but whose needs are often best met in the community. Nationally, they account for approximately 50 percent of Medicaid spending despite representing only 5 percent of those enrolled. As discussions continue around changes to the Medicaid program at the national level, states are continuing to seek innovative solutions for complex care populations. Effective complex care programs prioritize increased access to primary care, timely transitions from acute care settings and a multidisciplinary approach which prioritizes care coordination and includes pharmacy, behavioral health and social support services in the community (such as housing, employment and transportation).
Since 2013, the National Governors Association Center for Best Practices (NGA Center) Health Division has worked with 10 states and one territory, providing technical assistance to develop state-level solutions for complex care populations. Building Complex Care Programs: A Road Map for States guides state leaders in establishing and advancing complex care programs. It includes lessons learned from our work with states and effective practices gleaned from multiple pioneering state and local complex care initiatives.