It is widely recognized that good outcomes for patients with complex care needs are achievable when health care providers work locally and in tandem with community, government, and other partners. Interprofessional, cross-sector, and cross-agency collaboration between organizations that share responsibility for serving a group of individuals living in a community or particular geography is an effective way to stabilize health, decrease unnecessary utilization, improve care delivery, and reduce avoidable costs.
Rural areas present unique challenges and opportunities for individuals with complex needs and those providing their care. These environments may face healthcare workforce shortages, rising rates of opioid use, and geographical barriers to care. However, rural communities often foster close-knit social networks and an entrepreneurial approach to complex health and social issues.
Safe, stable housing is a key component of maintaining health and wellbeing. However, the identification documents required to qualify for public or affordable housing can be difficult to obtain for people with complex health and social needs. Individuals experiencing homelessness may lack the stability and resources needed to obtain the necessary documents for housing.
To address individuals’ array of needs, the field of complex care must work across sectors at both the individual and systemic levels to break down silos. Effective multi-sector partnerships are essential to building a lasting ecosystem that provides whole-person care for vulnerable populations and helps to address the social determinants of health.