Complex care seeks to improve health and well-being for people with complex health and social needs by coordinating and reshaping care delivery at the individual, community, and system levels. It addresses root causes of poor health through interdisciplinary care teams and cross-sector partnerships that deliver person-centered care based around participants’ own goals and priorities. These root causes extend beyond physical health and well-being to include social determinants of health including poverty, trauma, housing and/or food insecurity, and lack of access to care.
Why do we need complex care?
In the US, our systems of care — including healthcare, public health, social care, housing, education, and more — typically address an individual’s single need in isolation and are not designed to work together to meet multiple needs simultaneously. For individuals with the most complex health and social needs, lack of access to coordinated physical, behavioral, and social services results in poor health outcomes and the use of expensive services.
To see different results we must deliver care differently. Care must be:
- Person-centered: In complex care, individuals’ values and preferences guide all aspects of their care, supporting their realistic health and life goals.
- Equitable: Complex care recognizes the structural barriers to health, including systemic, institutional, and interpersonal racism, bias, and other forms of discrimination, and supports individuals and communities to overcome them.
- Cross-sector: Complex care works to break down the silos dividing fields, sectors, and specialties, and to build the integrated ecosystem necessary to provide whole-person care.
- Team-based: Complex care is delivered through interprofessional, non-traditional, and inclusive teams of medical, behavioral health, and social service providers, led by the individual themselves.
- Data-driven: Complex care freely shares timely, cross-sector data across team members and partners to identify individuals, enable effective support of consumer goals, and evaluate success.
By improving care for those currently falling through the cracks of our fragmented systems and encouraging health systems and payers to share power with community organizations, a complex care approach can help achieve health equity in the US. Learn more about who we serve here.
How does complex care work?
Complex care programs seek to help people with complex needs identify and meet their own health and well-being goals by coordinating access to a wide range of services and supports and by building individual self-efficacy, ultimately reducing costs linked to avoidable healthcare utilization and advancing health equity.
A complex care approach identifies and documents where and who the existing delivery system fails to adequately serve, and seeks to build interdependent ecosystems of care to meet both the immediate and long-term needs of these populations and the community at-large.
The National Center for Complex Health and Social Needs serves as a professional home for the growing field of complex care. Want to learn more? Read our Blueprint for Complex Care.
- Blueprint for Complex Care
- Integrating social care into the delivery of health care: Moving upstream to improve the nation’s health (A report from the National Academies of Sciences, Engineering, and Medicine)
- Core competencies for frontline complex care providers
- The Playbook: Better care for people with complex needs
- Building the value case for complex care toolkit
- Complex care startup toolkit