Rethinking care for patients with complex biomedical, psychiatric, and social needs; starting with what matters most to them.

The challenge

Patients with complex biomedical, social, and psychiatric needs face multiple barriers to care, including unmet basic needs such as safe housing and transportation, along with navigating disparate health and social service systems. Poor communication between clinicians and patients and families can lead to care that is misaligned with a patient's context, resulting in preventable harms such as falls from polypharmacy and missed opportunities for health screening.

As the population ages, this need is growing rapidly. Patients with concomitant medical and surgical or medical and mental illness, particularly older patients, are frequently the highest utilizers of acute care, from the emergency room to the ICU. Yet from their perspective, the health system operates in disconnected silos, with hospitalizations often disrupting the very care coordination they need most.

Our approach

Building on clinical services in the Division of Medicine in Psychiatry, LISCN studies patients' needs and priorities across the clinical and social spheres to develop innovative, integrated care solutions. Listening to what matters most to patients is our first step in changing the service paradigm.

Our work builds on the biopsychosocial approach to health first proposed by Drs. George Engel and John Romano at the University of Rochester, bringing together research expertise in prioritization and decision-making, implementation science, and health services research.