Ten Questions to Better Understand and Serve Your Complex Care Population

Publication Year: 2018
Patient Need Addressed: Chronic Conditions
Population Focus: Medicaid beneficiaries
Intervention Type: Best practices
Type of Literature: Grey

The CHRONIC Care Act and new CMS guidance promote assessment of functional and social needs as part of delivering more cost-effective, quality care to individuals with complex needs. This brief shares 10 questions required of California’s Medicaid managed care plans, which health plans and systems nationwide could consider for their risk assessment instruments.

Insights Results

Overview of article

  • To better understand the populations they serve and effectively organize care, leading health plans and accountable care organizations (ACOs) are beginning to gather person-level data about social determinants of health (e.g., access to food, housing)
  • The risk assessment is a natural process point for health plans and ACOs to include questions that specifically capture an individual’s functional and social support needs. This new knowledge can provide a clearer understanding of a person’s total need profile, and how it affects their health status; improve population-level risk stratification; and support delivery system efforts that better match people who have identified needs with high-quality, targeted interventions
  • California has taken a major step in this regard, as the state recently required all Medicaid managed care programs to incorporate 10 questions in their health risk assessment (HRA) that evaluate for function and social support needs


  • The following are the 10 topics to assess function and social support of needs: 1) Daily living; 2) Home environment; 3) Health literacy; 4) Social support; 5) Caregiver stress; 6) Potential for abuse; 7) Memory; 8) Fall risk; 9) Financial; and 10) Social isolation

Key takeaways/implications

  • Stakeholders may start to see HRA’s more commonly supported by policy / implemented at the state level