What are some commonly used terms in this field?

Get acquainted with some of the language used in the field of complex care here. For a deeper dive into complex care, take a look at our Blueprint for Complex Care.

Adverse Childhood Experiences (ACEs)– ACEs are stressful or traumatic early life experiences that have been recognized as significant risk factors for a host of mental and physical health problems later in life. The original Adverse Childhood Experiences Study was conducted by Kaiser Permanente and the Centers for Disease Control in the 1990s. ACEs have been shown to have a dose-response relationship with many health problems (i.e., the more ACEs a person has, the higher the risk of developing health problems).

Ambulatory Intensive Care Unit (Ambulatory ICU) – Ambulatory ICU is a form of primary care designed to serve exclusively individuals with unstable chronic illness, complex behavioral health needs (including addiction), and often many social needs. In an ambulatory ICU model, people who are chronically ill have regular, frequent primary care visits. These routinized visits facilitate better relationships and allow clinicians to understand and treat issues before they become health crises or require referrals to specialists. The model has been found to reduce costs and improve wellbeing and satisfaction.

Authentic healing relationships – An authentic healing relationship is a deep participant-provider connection that is built intentionally by the provider using methods such as motivational interviewing, listening to participant stories, harm reduction, and trauma-informed care. Authentic healing relationships are secure, genuine, and continuous: participants feel seen and heard, and providers follow through and establish appropriate boundaries. Authentic healing relationships are associated with increased motivation and more active health management from participants.

Behavioral health — Systems and services related to the prevention, diagnosis, and treatment of mental health conditions and substance use disorders.

Care coordination – Care coordination is the deliberate organization of consumer care activities between two or more providers, caregivers, or other individuals involved in a consumer’s care, in order to facilitate the effective delivery of healthcare services.

Complex care — A person-centered approach to address the needs of people who experience combinations of medical, behavioral health, and social challenges that result in extreme patterns of healthcare utilization and cost.

Complex care ecosystem — A local network of organizations from different sectors, fields, and professions that collaborate to serve individuals with complex health and social needs.

Consumer – A consumer is anyone who accesses and uses healthcare services. Consumers are sometimes referred to as patients, clients, or participants in other care settings.

Consumer engagement – Consumer engagement is the act of empowering the consumer – i.e., the patient, client, or participant – to be an equal and active member of the care team.

Cross-sector collaboration — An alliance between organizations from two or more sectors with the intention to share responsibility for a project, product, process, or other activities.

Cross-sector data sharingIndividuals with complex health and social needs often cycle through various systems, including healthcare, social services, and criminal justice, without cross-sector communication or coordination. Cross-sector data sharing agreements allow for data from multiple systems to be combined in order to gain a broader understanding of the gaps that exist across systems and to pinpoint process improvements to create systems better able to serve people with complex health and social needs.

Field — “A community of organizations and individuals: (1) working together toward a common goal; and (2) using a set of common approaches to achieving that goal.” (The Bridgespan Group)

Field-building — “Coordinating the efforts of multiple organizations and individuals around a common goal and creating the conditions necessary for them to succeed.” (The Bridgespan Group)

Harm reduction – Interventions designed to reduce the negative consequences of harmful behaviors, most popularly associated with substance abuse, are known as harm reduction interventions. These can take many forms, but common examples include needle-exchange programs and opioid replacement therapies.

Health Information Exchange (HIE)– A system that electronically links medical records across healthcare systems and organizations. HIEs can give providers a more complete picture of consumers’ medical history and healthcare utilization, facilitate coordination of care across multiple systems, and assist in population health monitoring and data gathering. HIEs must abide by the Health Insurance Portability and Accountability Act (HIPAA) and other laws that protect patient privacy.

Hotspotting – Hotspotting refers to the identification of outliers within any system. Within the context of treating individuals with complex health and social needs, it refers specifically to a data-driven process for the timely identification of high healthcare service utilization patterns in a defined region of the healthcare system.

Housing First – Housing First is a homelessness assistance model that prioritizes placing individuals in permanent housing quickly and with minimal barriers before addressing other or underlying issues. Unlike traditional housing models, which require individuals to “step” through different types of housing, participate in services, and demonstrate improvement (such as sobriety), Housing First provides a stable home without. Housing First models show 80-90% housing retention rates, compared with 30-60% retention rates in progression-based models.

Integrated care– Integrated care most often refers to the integration of behavioral health into the primary care setting and vice-versa. Integrated care aims to better treat the whole person, reduce the stigma often associated with substance use and mental healthcare, and improve coordination of care for consumers. Integrated care can also more broadly refer to cross-disciplinary models that address behavioral and social needs of consumers alongside medical needs.

Interdisciplinary care teams – Interdisciplinary care is an approach in which a diverse group of individuals works interdependently to effectively address multiple aspects of an individual’s wellbeing. Members of a team may include, for example, educators, physicians, social workers, nurses, lawyers, occupational and physical therapists, psychologists, and pharmacists.

Medication-assisted treatment (MAT) – MAT is the use of medications in conjunction with behavioral therapies and other interventions to treat substance abuse.

Person-centered care – An approach to care delivery that prioritizes the needs and goals of the individual and their family or support network.

Social determinants of health — “Conditions in the environment in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” (Office of Disease Prevention and Health Promotion)

Trauma — “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual wellbeing.” (SAHMSA)

Trauma-informed care — A framework to build safety and trust with participants in service of helping them improve their health. Trauma-informed care is a philosophical shift from blaming consumers for problematic health or health-seeking behaviors (i.e., “what is wrong with you?”) to understanding the roots of these behaviors in early life trauma (i.e., “what happened to you?”). A trauma-informed care approach assumes that all participants may have experienced early life trauma; recognizes that trauma shapes health, behavior, self-regard, and interaction with others; and works to avoid re-traumatizing participants.

Whole person care – Whole person care is care that coordinates all of the physical, mental health, addiction, and social services in a person-centered manner with the goals of achieving improved health and wellbeing through more efficient and effective use of resources.