Complex Care Program

What is Complex Care?

Complex Care offers personalized care for someone with long-term or chronic health conditions. This care is individualized to meet the needs of each patient. It is to help maintain a high-quality life and focuses on what is important to the patient.

Goals of the Program:

1. Improve Patient Experience
   1. Meet patient and caregivers needs
   2. Improve access to the right care
   3. Improve access to social services
2. Improve Health
   1. Improve health outcomes
   2. Equity of access
   3. Reduce/manage complex disease processes
3. Reduce Costs
   1. Reduce cost in service delivery
   2. Reduce avoidable ER use
   3. Reduce unnecessary hospital admissions

Qualifications:

• Patient age 65 or older

• 2 or more health conditions:
  • Renal
  • Cardiac
  • Diabetes
  • Respiratory
  • Prescription for Controlled Substance
  • Mental Health

-AND-

• 1 or more social determinant of health:
  • Food Insecurity
  • Housing Instability
  • Interpersonal Safety
  • Transportation Needs
  • Utility Difficulties

**Program details subject to change**