Health for Individuals with Complex Care Needs

Challenge

Hospitals and health systems are often not well positioned to meet the needs of individuals with complex care needs. These individuals often have multiple chronic medical conditions, suffer from substance abuse or mental health conditions rooted in trauma, and have multiple unmet social needs related to homelessness and poverty. Many of these individuals have hundreds of emergency department visits in a single year and are not able to achieve stability. These individuals typically represent just 1% of a hospital’s patient population, yet account for 25% of total healthcare expenditures. Their complex medical, behavioral, and social needs are not well served in traditional outpatient care models. 

Our Objective

We envision a healthier North Carolina where health systems work in partnership with community partners to provide comprehensive care and services to their patients with complex care needs, resulting in sustained health improvement and a reduction in avoidable healthcare spending.

Through our grantmaking, we seek to advance the understanding of how health systems and community-based organizations can best identify and stabilize patients with complex care needs, address unmet social needs and improve health outcomes while reducing avoidable hospital utilization. We seek to build evidence to support the systemic payment and policy reforms necessary to sustain and scale effective practices statewide. 

What We Fund

The North Carolina Bridge to Health Initiative  

The Duke Endowment’s primary funding strategy to support improving health for individuals with complex care needs is through the North Carolina Bridge to Health Initiative. This initiative is a pilot program that will build on the collective experiences and best practices of participating health systems. The Bridge to Health program is informed by WakeMed’s Center for Community Health and other effective programs. As the initiative moves forward, five additional participating health systems — Novant Health Forsyth Medical Center, Atrium Health Wake Forest Baptist, Cone Health, ECU Health, and UNC Health — are helping to shape the program’s design by contributing their expertise and insights gained from their experience in serving patients with complex care needs.

Bridge to Health is a program designed to identify and engage patients with complex care needs that often cannot be met in traditional outpatient settings. The program establishes and expands hospital-based transitional (bridging) clinics that are designed to serve patients with complex care needs by stabilizing their acute medical, mental health, and social needs while strengthening collaborative partnerships with primary care providers and community-based organizations to ensure continuity of care. Bridge to Health proactively provides patients with comprehensive, individualized care to improve patient outcomes and decrease the total cost of care by reducing hospital utilization for avoidable health conditions. 

The Endowment has allocated more than $9.8 million to advance the initiative. The multi‑year investment is supporting six health systems as they plan and implement the program. Technical assistance and program evaluation are being provided by the North Carolina Healthcare Foundation and the Duke-Margolis Institute for Health Policy. 

Advancing Innovation in Health for Individuals with Complex Care Needs

Improving health outcomes for individuals with complex care needs is a broad and emerging field, and The Duke Endowment anticipates continued learning through the funding of innovative programs and approaches that can inform and complement the North Carolina Bridge to Health Initiative. 

While we are not currently accepting additional applications from health systems to join the initiative’s first cohort of participating sites, we do anticipate releasing a request for applications for a second cohort pending outcomes from the initial pilot sites. In the meantime, we continue to consider funding requests that support improving health outcomes for individuals with complex care needs in North Carolina. These requests may be submitted through the pre-application process while the pre-application cycle is open via our online application portal.