Resources Supported by the Six Foundation Collaborative

The Six Foundation Collaborative is made up of The Commonwealth Fund, The John A. Hartford Foundation, Milbank Memorial Fund, Peterson Center on Healthcare, Robert Wood Johnson Foundation, and The SCAN Foundation. The purpose of the collaborative is to work together to improve health care delivery and outcomes for adults with complex health and social needs. Patients with complex needs are those with multiple chronic medical conditions, socioeconomic factors that hinder healthcare access, or a combination of both. The collaborative works with organizations that participate in value-based payment models, such as accountable care organizations (ACOs) and Medicare Advantage plans, to transform the care delivery system through evidence-based interventions that provide higher-quality care at a lower cost.

The Six Foundation Collaborative has established guidelines and resource material to help health system leaders and other stakeholders develop an understanding of the diverse populations with complex needs; identify effective ways of delivering higher-quality, integrated care at lower cost; and to accelerate the spread of these approaches across the nation. The collaborative’s ultimate goal is to have 30% of health care organizations participating in value-based payment models adopt proven interventions for adults with complex needs that improve person-level outcomes and lower overall costs of care by 2030.

The following resources are a product of the collaborative’s work.

How ACOs Are Caring for People with Complex Needs

Kristen A. Peck, Dartmouth Medical School; Benjamin Usadi, Alexander Mainor, Helen Newton, and Ellen Meara, Dartmouth Institute for Health Policy & Clinical Practice

ACOs are groups of doctors, hospitals, and other health care providers who work together to provide coordinated, high-quality care to Medicare patients. In order to understand how ACOs care for patients with complex needs, there must be an examination of their organizational strategies, contracting details, and leadership structures. This report describes specific strategies employed by ACOs that have comprehensive care management programs and processes for complex patients.

Strategies include:

  • Identifying people who are at high risk for adverse clinical events (often referred to as risk stratification)
  • Separating high-risk patients into subgroups with common needs (segmentation)
  • Improving care transitions across settings
  • Engaging individuals and their families in care decisions
  • Using programs that help patients address chronic illness.

Understanding the variation in ACO strategies is the first step in determining a standard of care for patients with complex needs. Through cross-sectional descriptive analysis of the fourth National Survey of ACOs, this report  shows that ACOs have increased their efforts to target populations with complex care needs but more needs to be done to develop and implement approaches to improving care delivery and developing a standard of care.

The Blueprint for Complex Care: Advancing the Field of Care for Individuals with Complex Health and Social Needs

Mark Humowiecki, Teagan Kuruna, Rebecca Sax, and Margaret Hawthorne, National Center for Complex Health and Social Needs; Allison Hamblin and Stefanie Turner, Center for Health Care Strategies; and Kedar Mate, Cory Sevin, and Kerri Cullen, Institute for Healthcare Improvement

 The US spends more on health care than any other industrialized nation, and much of that spending is concentrated on a small percentage of the population for whom behavioral health and social needs are major contributors to poor health outcomes. The goal of complex care seeks to address these gaps and provide better care at lower cost. This report assesses the current state of complex care strategies and provides actionable recommendations to ensure these strategies reach their full potential. The Blueprint for Complex Care is a joint project of the National Center for Complex Health and Social Needs, the Center for Health Care Strategies, and the Institute for Healthcare Improvement. The report makes the following actionable recommendations for organizations or individuals interested in improving complex care delivery:

  1. Develop core competencies and practical tools to support the standardization of educational programs and resources
  2. Further develop quality measures for complex care programs
  3. Enhance and promote integrated, cross-sector data infrastructures
  4. Identify research and evaluation priorities
  5. Engage allied organizations and health care champions through strategic communication and partnership
  6. Value the leadership of people with lived experience
  7. Strengthen local cross-sector partnerships
  8. Promote expanded public investment in innovation, research, and service delivery
  9. Leverage alternative payment models to promote flexible and sustainable funding
  10. Create a field coordination structure that facilitates collective action and systems-level change
  11. Foster peer-to-peer connections and learning dissemination.

This examination into the essential components of complex care delivery does not provide any fast and easy solutions. It does, however, provide a structure and a roadmap for stakeholders who want to start a collaboration that seeks to address the health needs of this most vulnerable population.