What is the High Need, High Care Population?

The High Need, High Care Population is a relatively new concept, and taxonomy is evolving. A 2014 statistical brief by the Agency for Healthcare Research and Quality reported that 1% of patients accounted for 22.8% of total health care expenditures. (1) As such, many institutions have undertaken efforts to identify these “high need” individuals, with the goal of reducing unnecessary utilization and costs through structured interventions. The National Academy of Medicine has identified three criteria that may inform identification of high need patients: a) total accrued health care costs, b) intensity of care utilized for a given period of time, and c) functional limitations. (2) A high need population can be fluid, as costs and intensity of care vary over time based on disease activity and psychosocial factors. Complex care is the framework for taking care of the high need population. Advocated by the Commonwealth Fund and the Robert Wood Johnson Foundation, complex care is a person-centered approach to address the needs of people who experience combinations of medical, behavioral health, and social challenges that result in extreme patterns of healthcare utilization and cost. (3)


 1. Mitchell E. Concentration of Health Expenditures in the U.S. Noninstitutionalized Population, 2014. Statistical Brief #497. November 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st497/stat497.shtml

2. National Academy of Medicine (2019, March 25). Effective Care for High Need Patients. Retrieved from: https://nam.edu/HighNeeds/

3. The Commonwealth Fund (2016, November 28). The Playbook: Better Care for People with Complex Needs. Retrieved from https://www.commonwealthfund.org/publications/newsletter-article/2016/dec/playbookbetter-care-people-complex-needs

What is the Vanderbilt Experience for the High Need, High Care Population:

Vanderbilt University Medical Center has developed the Vanderbilt Interdisciplinary Care Program (VICP) to provide complex care for high-need patients.  VICP defines the high need population based on the Hierarchical Condition Categories, which Medicare uses to project the expected risk and future annual costs of care. The HCC score is easily available in Epic. 

Patients who have HCC Scores of 3.0 and above, or 2.0-2.9 with 2 unplanned admissions at VUMC are eligible for the program. Patients admitted under the Hospital Medicine service are regularly screened for enrollment to VICP. Based on internal data, this population includes approximately 1% of all patients seen at VUMC in a 6-month period and represents over 10% of all inpatient admissions and total charges. (1) VICP employs multi-layered, patient-centered strategies to improve clinical care for VUMC’s high need population and seeks to understand which interventions decrease hospital utilization and improve clinical outcomes. Preliminary data demonstrates a 41% decrease in admissions and 38% decrease in ED visits among patients in the VICP program, compared to these patients’ healthcare utilization prior to enrollment. 

Patients meeting this criterion are offered to enroll in either the primary hospital program (PHP) or the primary care program. The primary hospital provider program allows the patient to have a consistent inpatient team and maintain their primary care provider especially if they have long-standing relationships with their PCP, or they live a significant distance from Vanderbilt. In the primary care program, the VICP takes care of the whole continuum of care for this population.


(1) Tableau. Vanderbilt Medical Center Data. Retrieved December 2018.

(2) Tableau. Vanderbilt Medical Center Data Retrieved March 2019.

The Vanderbilt Interdisciplinary Care Program

The Vanderbilt Interdisciplinary Care Program (VICP) is a team of physicians, advanced practice providers, case managers, social workers, pharmacists, and nurses whose goal is to provide care for patients that have an established pattern of increasing healthcare utilization. The goal is to provide and coordinate care within both the inpatient and outpatient settings with a desire to improve health outcomes for this population. By routinely assessing environmental, behavioral, emotional, physical, functional and medical needs using standardized tools, the healthcare team will uncover potential barriers to achieving optimal healthcare outcomes.


givenow button.jpg 

To the VUMC Division of General Internal Medicine and Public Health

Your contribution will support ongoing education and training in Internal Medicine and Public Health.

Specify VICP if you would like your donation improve this program's research, education and patient care.