Caring for socially complex patients: Perspectives and suggestions

High-need high-cost patients, many of whom are experiencing poverty, use a large portion of health care resources. Despite receiving more care, such patients often experience poor health outcomes. Teams providing intensive ambulatory care interventions were interviewed regarding how they view the work of serving socially and medically complex patient populations.

Researchers conducted semi-structured, qualitative interviews with nine ambulatory care team members and six "usual care" team members, focused on multidisciplinary staff experiences. Interviews were performed at a Federally Qualified Health Center caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit intervention. The staff noted social, behavioral, and medical challenges leading to patient-health care system mismatch. Team members cared for HNHC patients by addressing both psychosocial and clinical needs together; staying connected to patients through chaotic periods; reinforcing commitment and cohesion among interdisciplinary team members; and being flexible enough to create individualized care tailored to each patient's situation. Participants more often defined success as improving patient engagement, as opposed to reducing utilization or cost.