Managing Complex Care: Improve Effectiveness through Clinical Integration, Population Health Best Practices

Posted by Continuum on Feb 9, 2016 11:00:00 AM


Many primary care physicians (PCPs) struggle to provide high-quality care for patients with complex needs. 

A recent international survey* confirms this challenge: Nearly 25 percent of U.S. PCPs say they are not well-prepared to care for people with multiple chronic illnesses. 

Hurdles include lack of care coordination and gaps in access, according to the Commonwealth Fund study. Its authors call for strengthening the nation’s primary care infrastructure, in part by improving communication among providers and increasing access to care.

Two overarching approaches can help doctors achieve these goals, while also reducing the disproportionate costs of complex care: participation in a clinically integrated network (CIN), and use of population health best practices.

To learn more about the Five Pop Health Critical Elements, download our checklist now.  

CIN Advantages

iStock_000019826602_SMALL.gifA CIN, made up of PCPs and a wide range of specialists, can provide the infrastructure and resources needed to deliver accessible, well-coordinated, cost-effective care. The most successful CINs include only those providers who deliver high-quality care at lower overall costs. In essence, the CIN is like an all-star team, with the staffing and technical support needed to ensure the best possible patient outcomes.

CINs can also support the use of best practices in population health management. These include various activities, strategies and systems that enhance care and lower costs for particular patient populations.

While CIN membership is not a prerequisite, the network’s shared resources can make population health initiatives more feasible.

Together, these approaches align with healthcare reform and support physicians’ participation in value-based incentive programs.

Population Health Strategies

Best practices in population health include five critical elements:


 To learn more about each of these strategies, download our Five Pop Health Critical Elements Checklist. 

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Topics: Triple Aim, care continuum, Healthcare, gaps in care, population health tools, CIN

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