Whole Person Longitudinal Complex Care—
the Missing Piece for Complex Patients
Complex Patient Characteristics
Complex patients are those who have not only multiple chronic conditions, but also serious chronic conditions, like heart and lung. Complex patients represent both human suffering and societal cost. Their functioning often depends on a frail and delicate equilibrium that can, like a house of cards, easily come tumbling down. And among Medicare beneficiaries, the top 20% spends 84%.
Complex patients have multiple chronic, acute and subacute conditions that together present these challenges:
- The multiple conditions can interact unpredictably, especially when there are changes, even small ones;
- The multiple treatment regimens for the multiple conditions often conflict;
- The multiple conditions can give rise to confusing, often vague, undifferentiated symptoms;
- These patients often have problems with care coordination, compliance, family and caregivers, and maintaining a healthy psychosocial state;
- Rapid and serious overall decompensation can suddenly materialize when problems arise in just one area.
Nihilism Justified?
Even though chronic conditions and complexity has been a main target of health care reforms since the 1990s, such as the chronic disease management movement, the 2004 Medicare Modernization Act, Chronic Care Management, transitional care, MIPS, and pay for value, complex patient costs continue to climb. There is some nihilism, both in the health carefield and among patients, about whether it is possible to improve outcomes and cost once serious chronic conditions have set in. Is nihilism justified? Or is there a missing piece?
No, nihilism is not justified. From my study of my 2010-2014 complex patients with very high RAF (>3.0 on HCC v12) from serious chronic conditions that map to HCCs, during years when they have no acute conditions serious enough to map to HCCs, their costs are unremarkable. It is during years when serious acute conditions arise that costs soar, 4.4x on average. The answer jumps out—two things are needed:
- Every minor adverse event must be nipped in the bud with early and effective treatment that also does not upset the delicate equilibrium among existing treatments, and
- The patient's prior resilience must be maximized so he/she can withstand acute events and can, if decompensation still occurs, minimize the severity.
Indeed, by practicing that type of complex care, my medicare patient panel for 2010-2014 had a risk-adjusted hospitalization rate of 33% less than national Medicare average and total cost of care 39% less.
Whole Person Longitudinal Complex Care, made possible by APCC Care
I believe that the missing piece is Whole Person Longitudinal Complex Care by all the complex patient's providers. This care runs on a unified whole person clinical reasoning and treatment logic generated by the generalist PCP from both his/her own evaluation and management, and from integrating that of specialists, ancillary care providers, nurses, and pharmacists—the whole care team. The PCP in turn transmits this unified reasoning and logic, along with regular updates, back to the team —the PCP coordination of care.
I believe a PCP who provides All-around, Personalized, Continuous, Coordinated (APCC) Care can best generate and transmit to all providers this unified whole person clinical reasoning and treatment logic for the Whole Person Longitudinal Complex Care, as well as provide much of or the bulk of this care.
An APCC Care PCP has broad expertise across organ systems and across inpatient as well as outpatient care settings, attends on the patient when admitted, maintains focus on the whole patient, understands and follows all aspects and all problems of the complex patient, knows how to balance and tailor multiple treatment regimens to optimize outcome, performs regular reassessments and fine-tuning to maximize complex patient resilience, and as part of care continuity, both usually has room for urgent visits and is usually availabe on call after hours. Therefore the APCC Care PCP can meet the challenges complex patients present and indeed is key to solving the complex care problem.
But how to bring about APCC Care and Whole Person Longitudinal Complex Care? I am writing about it.
Below are my posts to date on Complex Care.
See my APCC Care Page →
Dennis Fong's Complex Care Series
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Whole Person Longitudinal Complex Care - the Missing Piece
(Sep 6, 2025) · Read & comment on LinkedIn -
Whole Person Longitudinal Complex Care Needs True Generalists
(Sep 12, 2025) · Read & comment on LinkedIn -
Undervaluing of Cognitive Work
(Sep 18, 2025) · Read & comment on LinkedIn -
Linking Payment for Cognitive Work to Outcomes - One Lever
(Sep 25, 2025) · Read & comment on LinkedIn -
Linking Payment for Cognitive Work to Outcomes - A Second Lever
(Oct 2, 2025) · Read & comment on LinkedIn -
True Cost Transparency - Straight Percentage Copay
(Oct 15, 2025) · Read & comment on LinkedIn -
True Cost Transparency to Fix Complex Patient Costs
(Oct 24, 2025) · Read & comment on LinkedIn -
How to Improve Both Complex Patient Outcomes and Costs
(Oct 29, 2025) · Read & comment on LinkedIn
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