Supporting Individuals with Complex Needs: Care Delivery that Provides the Right Services and Supports in the Right Settings

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October 4, 2023

Courtney E. Burke
Sally R. Dreslin


Individuals with complex medical, behavioral, and social needs often cycle through health, behavioral health, and social service systems and frequently end up in an inappropriate care setting or with insufficient services and supports. When individuals with complex needs have trouble accessing the right supports and inappropriately end up in the wrong setting, they are not being optimally supported. Accepted public policy and best healthcare practices emphasize that such individuals should be cared for in the most integrated setting possible—those that a person would typically live in which do not typically include institutions or other congregate (centralized residential facility) care settings.

This policy brief provides an overview of how complex needs can be understood, why this issue is important for policymakers, how “complex care” is defined, and why current service systems have difficulty supporting these individuals. In addition, because the implementation of cross-sector and innovative models of care delivery are key to addressing this system-wide challenge, the brief highlights a sample of promising care delivery models in New York State. However, although there are models that have been shown to improve the coordination of services across different programs and systems, there are not a lot of rigorously evaluated studies for the wide variety of people with multiple complex needs.

This paper presents emerging and promising models by complex needs care providers that were recently convened for a discussion of best practices by the Rockefeller Institute of Government in collaboration with the Step Two Policy Project and in coordination with the NYU McSilver Institute for Poverty Policy and Research. The models in this paper have not yet been rigorously evaluated by outside entities. The providers discussed here and their partners have conducted self-evaluations using metrics such as patient satisfaction, reductions in inpatient stay days, or health outcomes. Given that these providers have seen early success in these areas, the brief takes learnings from the experiences of these providers and suggests where policymakers might focus their efforts to improve care. The paper also makes recommendations as to how to develop these ideas and models further to best support people with complex needs.

Read the full policy brief.