Essential Competencies for Addressing the Needs of High-Utilizing Patients

Improving outcomes and lowering costs of serving high-utilizing patients requires greater knowledge of the competencies needed by team members to succeed in caring for them. Patients in this population, characterized by high use of hospital and ED services, often have multiple chronic conditions, problems associated with extreme poverty such as homelessness and hunger, and needs for social and behavioral services beyond the health care sector. To succeed, in addition to an accommodating fiscal and organizational environment, providers must be equipped with the requisite expertise for implementing care plans that embrace a more holistic view of patients and their needs. The project’s three objectives are to: 1) assess the status of current and past efforts relevant to caring for high-needs individuals (through a comprehensive scan of such efforts and brief interviews with staff of programs showing particular promise), 2) elicit critical competencies, associated care tasks, and roles of members of effective teams (through site visits at programs that typify promising models and in-depth interviews with providers), and 3) explore options for preparing health workers to develop essential competencies (through eliciting input from experts in health professions education).