Tools to support the understanding and identification of a complex care population, plan a care model and workflow, and anticipate legal and business needs. 

• Understand population root cause needs: As you are building your complex care program, uncovering and addressing the root causes of negative health and social outcomes is an important foundation. These supports assist with stabilization and maintenance of health and wellness. Using multiple sources of data to better understand the needs of your target population will strengthen the design and impact of your initiative. It’s often easier to address the immediate causes of negative outcomes while disregarding the more fundamental and challenging root causes of instability, but without addressing those root causes, it’s hard to meaningfully improve outcomes.
• Planning: Planning is an ongoing process throughout the lifecycle of your complex care program. Continually convening the right stakeholders and asking the right questions will help improve your program design and impact. These comprehensive planning tools are collected here to support programs from idea generation to care delivery. Keeping a written methodology of your planning processes will allow for future replication and auditing for quality improvement. Good plans allow for the flexibility to learn, grow, and change program design as new experiences and insights are gained throughout the process.
• Legal and business: The legal and business activities of complex care programs serve as the foundation for which to build and grow innovative programs. New and emerging models of complex care often challenge standard legal norms and business practices. New tools and techniques are being developed to support organizations navigating these new organizational and clinical environments.

Tools to support the implementation of a complex care model including triage, outreach, engagement, intake, and clinical support.

• Participant identification and triage: Targeting and identifying the right populations is critical to the success of complex care interventions and programs. These resources will help organizations to identify and triage populations through a variety of data sources, provide tips on risk stratification, and present examples on exclusion and inclusion criteria.
• Intake: Intake in a complex care program serves two purposes: engagement of individuals and collecting information. Individuals are generally chosen for programs based on provider and/or data-driven referrals that are informed by inclusion and exclusion criteria. After initial selection, individuals must be engaged to assess their interest in participating in a program. If they decide to proceed in the program, staff must assess the participants’ holistic needs and strengths and work together to create a mutually agreed upon plan of care and action.
• Clinical protocols: Complex care programs have distinct protocols due to the complexity of individuals’ health and social needs. Consider developing protocols and workflows that focus on staff and participant safety, crisis planning, and a quick and healthy response to critical events.

Tools to support metric identification, data collection and analysis, and process improvement.

• Metrics: A comprehensive, ongoing evaluation mechanism for complex care programs is essential to maintain efficient and effective operations and demonstrate value and impact to populations served and financial partners. Diverse metrics that describe operational, financial, utilization, quality, and participant/provider experience/story outcomes will enable programs to remain responsive, transparent, and accountable to internal and external stakeholders. Continual feedback of outcomes to program staff and stakeholders is best practice to foster a culture of continuous quality and performance improvement.
• Data collection and analysis: A key element of complex care programs is the ability to collect and analyze diverse sources of information to both monitor and evaluate targeted population health outcomes and the effectiveness of interventions. Data points measuring key processes, outcomes, and the experience of care from both the perspective of the participant and staff/providers are important inputs for establishing effectiveness and value. Data analytic skills and capacities will vary across organizations and partners often collaborate to complement each other’s information management and analysis capabilities. Consider creating an inventory of data resources and mapping those resources to key program process and outcome metrics. This will help you identify and organize what data is accessible.
• Process and outcomes improvement: Continuous improvement of processes and outcomes is the hallmark of a high-functioning complex care organization and program. There are many tools and resources available to support improved program implementation. Organizations must commit to a culture of improvement and evolve to meet the changing needs of their stakeholders and populations being served.

Tools to support the recruitment, training, and management of a complex care team.

• Staff recruitment: Complex care is a challenging environment to work in; finding and choosing staff that fit the organizational culture and have the requisite communication, technical, and clinical skills is imperative to successful program implementation. Structuring the hiring process so that staff and employers get to know each other well will be mutually beneficial and help with recruitment and retention of staff that are a good fit to the organization, program, and population served.
• Onboarding and training: Staffing complex care programs requires finding the right person for the job as well as robust onboarding practices to lay the foundation for successful communication and collaboration between team members. The best onboarding programs teach new team members how to do the job instead of using it as an opportunity to “weed out” new team members. Ongoing training is essential in keeping staff motivated and supported to meet the challenges they are encountering in the field. High-functioning organizations are proactive about the mental and emotional needs of their staff.
• Team and staff ongoing improvement: High-functioning staff and teams enable quality care delivery for populations with complex needs and in vulnerable situations. Organizations must be proactive in fostering an environment where interprofessional teams can thrive and adapt to stressful and ever-changing work environments.
• Management and leadership: Effective management and leadership is one of the most important elements to creating and sustaining a complex care model. The interprofessional and multi-sector nature of complex care requires a broad set of tools that leaders must use to foster outcomes, partnerships, and sustainability of programs and initiatives serving populations with complex health and social needs.

Tools to support multi-sector and community coordination.

• Assessing community resources and identifying a target problem: Defining and identifying your target population and mapping available community resources is an essential component of complex care interventions. These assessments will enable programs to link individuals to needed services and fill care gaps left over from traditional healthcare delivery systems, especially concerning unmet health-related social needs. Identifying and building relationships with community partners is key to providing holistic, person-centered care. Collaborations between organizations are often mutually beneficial and can expand over time with stewardship, resource sharing, and aligned incentives.
• Convening community stakeholders: Communities working together on shared goals can make a significant difference and build structures that support the health and wellness of the population, especially the most vulnerable and marginalized. These resources provide tools to increase consumer participation and leadership, convene and manage stakeholders and working groups, as well as guidance on building trauma-informed systems of care.
• Data sharing: Data sharing and interoperability of data systems between organizations and sectors has the potential to make a big difference in the lives of individuals with complex needs. There are state and local regulatory and compliance hurdles that can be overcome to facilitate sharing and enable collaboration between organizations. Organizations across sectors are finding innovative ways to access and integrate data to improve service delivery and improve health and social outcomes.
• Referrals: Individuals with complex needs often rely on a community of organizations providing holistic services to meet their diverse needs. Management and tracking of referrals between organizations is key to improving access and service delivery.
• Strategy and business: Creating a business strategy and action plan that supports a viable financial model and demonstrates the value and return on investment is essential to sustaining and growing your complex care intervention. Identification of strategic partnerships and alignment of financial incentives will support sustainable program delivery.

Tools to support broad communication and program scaling.

• Communications: Dissemination and communication of complex care initiatives serves to strengthen the programs, further develop the emerging field of complex care and broaden our collective impact. These resources will help your program communicate your story and impact to a variety of stakeholders from a variety of perspectives, including ways to use the perspectives and experiences of the participants to highlight successes and challenges and to advocate for resources.
• Growth and sustainability: Sustaining complex care initiatives beyond the initial pilot intervention and/or grant period is challenging. This module provides resources on making the business case for your interventions and approaches to building a sustainable business model for your program.
• Advocacy (NEW!): Providing direct healthcare to consumers often calls attention to broader social and policy issues that can be addressed through advocacy. Additionally, becoming an advocate for social and policy change is an important way to educate the public about the problem and initiate broad social change. These resources will help you develop and implement an advocacy campaign to address your healthcare or social issue.