Who are people with complex health and social needs?

Complex care seeks to improve health and well-being for people with complex health and social needs. This is a diverse group that includes individuals with multiple chronic physical and behavioral health conditions who often face social barriers such as homelessness and unstable housing, food insecurity, and/or lack of transportation, as well as frail elder adults and people with serious illness. Individuals’ chronic health conditions and social barriers are often, but not always, exacerbated by systemic inequities such as racism, ableism, ageism, and poverty.

Our existing care systems — including healthcare, social services, legal and criminal justice, and more — and workforce are not equipped to provide the time and attention necessary to build trusting relationships and support individuals dealing with multiple intersecting health and social challenges in meeting their needs, values, and preferences. Clinical care often focuses on the immediate clinical issues patients present with, and fails to address and/or account for the social and economic drivers of health. 

Individuals with complex needs often encounter:

  • Impacts of individual and community-level trauma;
  • Providers who dismiss or demean their experiences and perspectives; 
  • Providers who do not look like them, speak their preferred language or have adequate training in providing culturally-appropriate care;
  • Social networks that are unable to provide the necessary physical and emotional support;
  • Complex and difficult-to-navigate systems (e.g., public benefits);
  • Systems that lack accountability for poor health outcomes; 
  • Neighborhoods that lack essential services and amenities required for optimal health, including grocery stores, pharmacies, parks, sidewalks, etc.
  • Limited services from under-resourced community-based organizations and government agencies meant to address the social and economic drivers of health, including food, housing, and financial support; and/or
  • Structural, institutional, and interpersonal racism, bias, and other forms of discrimination.

Complex care initiatives often focus on specific groups, or subpopulations, of individuals that share one or more major medical, behavioral, and/or social drivers, such as children with complex needs, individuals with substance use disorders who are experiencing chronic homelessness, or frail older adults. Collectively, these overlapping subpopulations are connected by the fact that the current systems of health are failing to meet their needs. 

Meeting individuals’ complex health and social needs requires a holistic understanding of the drivers of health, care delivery by interdisciplinary teams, and coordination of care across settings, services, and sectors. It requires understanding the individuals’ strengths, assets, and resilience to help them  achieve self-identified goals. And it requires leadership from advocates and leaders with complex health and social needs in designing programs, approaches, and policies to improve care.

Ultimately, efforts to reshape our approach to health using complex care principles and approaches can benefit all of us by building a more humane, holistic, and person-centered system.

Find the core competencies for providing care for individuals with complex health and social needs here.

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