Reducing Care Delays for Patients with Complex Needs

Care delays remain one of the most persistent challenges facing U.S. health systems, with profound implications for both quality and equity. While timely access matters for all patients, delays often fall most heavily on individuals with complex needs, those who require support across multiple conditions, services, and settings.

For these patients, care is rarely a single appointment or isolated episode. Instead, it involves ongoing navigation through referrals, transitions, follow-up care, and community services. When any part of that pathway slows down, the effects can quickly compound, shaping outcomes, experience, and trust in the system itself. Reducing delays, therefore, is not simply an operational concern. It is increasingly viewed as a structural equity issue, reflecting how well health systems are designed to meet the needs of patients facing the most significant clinical and social complexity.

Who Are Patients With Complex Needs?

Patients with complex needs are generally those living with multiple chronic illnesses, disabilities, severe mental health conditions, and/or social circumstances that complicate access to care. Many also rely on a mix of medical, behavioral, and community-based supports.

Because these individuals interact with multiple providers and services at once, they are particularly vulnerable to fragmentation. Delays that might be manageable for patients with straightforward needs can become significant barriers for those requiring coordinated, continuous care.

In practice, these delays contribute not only to poorer health outcomes but also to widening disparities, especially for patients already facing structural disadvantage within the healthcare system.

Where Care Delays Most Often Emerge

Although delays can occur at many points, they are especially common at transitions, when responsibility shifts between providers or settings. For patients with complex needs, these handoffs are frequent and often high-stakes.

Bottlenecks frequently appear in areas such as:

• Referral pathways between primary and specialty care
• Discharge planning and the move from hospital to home or post-acute care
• Connections between clinical services and social or community-based supports.

These are not simply administrative gaps. They reflect deeper misalignment between sectors that often operate under separate funding, data systems, and accountability structures. In some cases, delays are further compounded when patients require coverage exceptions, such as single case agreements to access out-of-network specialty services, adding another layer of complexity to already fragile care pathways. Some organizations, including care coordination partners such as Your Missing Piece, are explicitly focused on helping systems and patients navigate these complex access challenges more efficiently.

Care Coordination as a System-Level Solution

One of the clearest opportunities for reducing delays lies in strengthening care coordination. Health systems are increasingly recognizing that integrated care models are not optional enhancements, but essential infrastructure for timely and equitable access.

Multidisciplinary care teams, bringing together clinicians, behavioral health providers, pharmacists, social workers, and community partners, can help reduce bottlenecks by improving communication and decision-making across settings.

Practical approaches may include:

• Dedicated care coordinators or patient navigators
• Shared care plans that move with the patient
• Proactive follow-up after referrals or discharge
• Clearer pathways between health services and social care resources

When coordination functions well, patients spend less time waiting between disconnected episodes of care and more time receiving support that reflects their full range of needs.

Structural Barriers That Reinforce Delays

It is also essential to recognize that delays are rarely driven solely by clinical complexity. They are often intensified by system-level constraints that disproportionately affect underserved populations.

Social determinants of health play a significant role. Limited transportation, unstable housing, food insecurity, or lack of caregiving support can all prevent patients from accessing timely care, even when services exist.

At the same time, many systems continue to face serious interoperability challenges. When clinical providers and community organizations cannot easily share information, referrals slow down, transitions become riskier, and patients are left repeating their histories across settings.

Workforce shortages and burnout further strain capacity, especially in safety-net environments. And while digital tools may help reduce delays through telehealth or streamlined scheduling, they can also deepen inequities for patients experiencing digital exclusion or limited broadband access.

Taken together, these barriers underscore why timeliness must be addressed through an equity lens, rather than treated as a narrow performance issue.

Policy-Informed Pathways to Improvement

Because care delays reflect fragmentation across sectors, policy frameworks and payment incentives play a central role in shaping solutions.

Promising strategies include:

• Payment models that reward coordinated, whole-person outcomes rather than isolated service volume
• More substantial alignment across Medicaid, behavioral health systems, and community-based supports
• Regulatory and infrastructure investments that enable secure cross-sector data sharing
• Long-term workforce development that supports multidisciplinary models of care.

As accountability shifts toward system-wide outcomes, reducing delays for complex-needs populations represents a critical opportunity to advance both efficiency and equity.

Building Timely Care Pathways for Equitable Access

For patients with complex needs, delays are rarely the result of individual behavior or isolated clinician decisions. More often, they reflect systems that were not built to support multimorbidity, overlapping social challenges, and care delivered across multiple sectors. Improving timeliness requires health systems to prioritize integration, coordination, and cross-sector collaboration, ensuring that care pathways are designed around patients rather than institutions. As health equity becomes a central goal of healthcare policy and leadership, reducing care delays for those with the most complex needs may be one of the most meaningful markers of progress.