For decades, PFCC partners’ work has elevated community voices throughout the organizations and programs that provide health care in the US. Catalyzing improvements that center the priorities, preferences, and goals of patients and their family caregivers.

PFCCpartners is built on the foundation of their own lived experiences as patients and family caregivers. It provides them with a unique understanding for what approaches result in sustainable and impactful engagement.

CBC Solutions is proud to partner with this group as we have a symbiotic relationship and belief in what the healthcare system could be and desire to be catalysts for change. Recently we had the pleasure of presenting “Navigating Vulnerable Populations through Complex Care” at a PFCCparnters Community of Practice workshop. The presentation can be viewed here.

We thank PFCCpartners for allowing us to present and look forward to a lasting partnership. To learn more about PFCCpartners, click here.

CBCS cares for the communities we serve. Currently, we are working on the High Utilizers of Virginia (HUV) program in Northern VA. Our HUV program staff works closely will all existing resources that connect with our common patients & those resources that need support. We are happy to announce that our organization donated thousands of dollars to ensure these nonprofits, including the Fredericksburg Regional Food Bank, The Lamb Center, and Hope Distributed can continue to serve those in need in the northern VA area.

Success comes from working with community partners to make a difference for those who need it most!

By Enrique Enguidanos, MD, MBA

The High Utilizer of Virginia (HUV) program reduces duplication of efforts while improving the quality of care for enrolled members. Improved care collaboration and 24/7-member access to support provided by Community Based Coordination Solutions (CBCS) has been integral to this program’s success in reducing high-cost utilization and improving outcomes—especially for members with behavioral health diagnoses.

The Challenge

Vulnerable patient populations often struggle to navigate a healthcare system built for providers, not for patients. This is true even when case management services are provided. When patients are unsure of available options, they turn instead to high-cost acute care, fail to receive appropriate follow-up, and inevitably end up back in the hospital.

The result? At least $47 billion (1. Accenture, 2021) in unnecessary annual care costs from ED utilization as just 5% (2. Jared OrtalizaMatthew McGoughEmma Wager Gary Claxton, and Krutika Amin, Peterson KFF, November 2021) of the population accounts for half of all healthcare spending in the US.

For vulnerable patients with behavioral health conditions, the needs become even more complicated. Currently, an estimated 34 million, or 17%, of adults (3. Ken Thorpe, Sanjula Jain, and Peter Joski, January 2017) in the US live with comorbid chronic and behavioral health conditions. In high-cost, high-utilization populations, that percentage is higher at 40%. Creating appropriate programs to support these individuals often requires significant staff, time, and financial resources as well as a keen understanding of the populations served. Without these resources, patients revert back to the hospital as their default choice for receiving care.

At the Department of Behavioral Health and Developmental Services (DBHDS) in Richmond, Virginia, leadership was facing significant overcrowding of state psychiatric hospitals while also navigating staffing shortages across the board. As a result, DBHDS was actively looking for a better way to support their members with behavioral health conditions—especially in light of the Covid-19 pandemic. A majority of members were enrolled in Medicaid, and the urban area meant a solution was needed that could meet the varied needs of a racially diverse population.

Suzanne Mayo, Senior Director of Patient Continuum Services at DBHDS shared, “We see CBCS as the glue that creates a cohesive care experience for each of our patients. Some of that care is clinical, but ultimately it all always comes down to the needs of the patient at that moment and what needs to be done to support them that day.”

The Solution

DBHDS partnered with CBCS to enroll patients with a pattern of high-state psychiatric hospital utilization in the High Utilizers of Virginia (HUV) program. Through the program, enrolled patients could receive additional services that went above and beyond those offered through traditional case management. These wraparound services were provided by CBCS staff, facilitating improved care without a need to increase DBHDS headcount. Suzanne Mayo, Director of the Office of Community Integration at DBHDS, shares: “Like many others, our health system was really impacted by Covid-19, and one of the biggest challenges we’re facing is staffing. Both hiring and retaining staff has been a challenge, which ultimately impacts the services we can give at the state psychiatric hospital and creates added pressures that limit the direct care we can realistically provide. We needed the support provided by CBCS to provide the needed services that go beyond what our case management teams could offer.”

The program utilizes CBCS community workers who are available 24/7 to help enrolled members overcome barriers to care—such as helping individuals secure transportation to appointments, housing, prescribed medications, or other ancillary care needs. Additionally, CBCS works closely with other stakeholders—such as private providers or public community systems—to coordinate care and reduce redundancies in services for improved cost savings.

“There are multiple mental health systems in Virginia beyond DBHDS that our patients touch—in the community, in private practice, or through the state,” Mayo continues. “We see CBCS as the glue that holds all those pieces together to create a cohesive care experience for each of our patients. Some of that care is clinical, but it always ultimately comes down to identifying what needs each patient has in that moment and what needs to be done to support them that day.”

Collaborative programs like those offered through DBHDS are also effective for managing other conditions beyond routine mental healthcare such as substance use, opioid use, and even chronic conditions. By engaging with patients at the point of crisis, care transitions improve—as do long-term care outcomes.

Engagement—especially with a first or second follow-up visit after a crisis for any condition—really enhances treatment success. By providing good wraparound services and developing positive care relationships from the beginning, we can help patients be in a much better state and transfer to a lesser acute care coordination program quickly and effectively.

Ultimately, a successful high-utilizer program comes down to 24/7 support for acute care, immediate access to necessary wraparound services, and efficient coordination between stakeholders for better follow-up. Leveraging these key principles, bridge programs like those offered by CBCS are proving effective in supporting optimal care at the appropriate acuity level for individuals with behavioral health, substance use, opioid use, and medical diagnoses, too.

Outcomes and takeaways

The HUV program has been met with significant, measurable success. Within a year of implementation, the program achieved:

  • 97% reduction in state psychiatric hospital admissions
  • 82% reduction in state psychiatric hospital admit days
  • 30% reduction in emergency department visits
  • $2.1M in annual cost savings

Today, DBHDS is continuing to expand the program to other locales in Virginia—adapting key elements to better support the unique demographics in each community. Additionally, DBHDS has expanded member enrollment in the HUV program to include both those who have been discharged from the state hospital and those who are at risk for being admitted to the state psychiatric hospital to further prevent unnecessary high-cost utilization.

Ultimately, this program has shown that the more additional support we can provide to individuals—especially vulnerable individuals who are at high risk of ending up in institutions—the better. We have seen a lot of value in the program—financially, in services provided, and in achieved outcomes. By focusing on the little things on an individual level, it has made a huge difference overall.

About the Author

Dr. Enrique Enguidanos has over 20 years of clinical experience in Emergency Medicine, much of this time also serving in organizational and systems management roles. For well over a decade, he has developed and fine-tuned systems of care and community management systems that have proven very effective for frequent utilizers, and that is now organized in a manner that allows CBCS to continuously reproduce care results across varying communities and health care systems. Learn more about CBC Solutions by visiting


  1. The rising cost of healthcare system complexity – Accenture
  2. How do health expenditures vary across the population? – Jared OrtalizaMatthew McGoughEmma WagerTwitterGary Claxton, and Krutika Amin

Prevalence And Spending Associated With Patients Who Have A Behavioral Health Disorder And Other Conditions – By Ken Thorpe, Sanjula Jain, and Peter Joski

Join us in sunny Sacramento, CA, September 21-23, 2022, for the seventh annual conference for the complex care field. CBCS is a proud sponsor of this important event.

The theme of this year’s event is Values and value in complex care. We know that complex care offers value to consumers, communities, providers, payers, and more. How can that value be defined, measured, and demonstrated, beyond reductions in cost and utilization? We know that our shared values of health justice and equity sustain us in doing this critical and sometimes difficult work. Can we translate these shared values into sustained financial and institutional support?

If you are attending, please stop by Booth #107 to say hello & receive a special gift that in turn helps our vulnerable homeless population. Everyone will be “buzzing” about these so don’t miss out!

Join CBCS as we present: Establishing a high utilizer program (Review of High Utilizers of Virginia implementation) in Ballroom A7 on Thursday, September 22 – 7:30 am – 8:45 am.

This will be a moderated panel discussion with members integral to the success of the HUV (High Utilizers of Virginia) program. Launched in 2021, the HUV program has demonstrated dramatic outcomes (including a robust financial ROI within months of launch), and has been embraced by enrollees and community resources.  The presentation will include audience participation in a thought-provoking dialogue on establishing an effective high utilizer program.


Dr. Enrique Enguidanos – Founder and CEO at CBCS

Pronouns: He/Him

Dr. Enrique Enguidanos has over 20 years of clinical experience in Emergency Medicine, much of this time also serving in organizational and systems management roles. For well over a decade he has developed and fine-tuned systems of care and community management systems that have proven very effective for frequent utilizers, and that is now organized in a manner that allows CBCS to continuously reproduce care results across varying communities and health care systems.


Jamie Elzie, LCSW 

Pronouns: She/Her

Community Transition Specialist- NVMHI & PGH

Virginia Department of Behavioral Health and Developmental Services

Jamie Elzie is a Licensed Clinical Social Worker with over 20 years of experience working in the public sector.  Jamie started her career working for the Richmond City Department of Social Services working with children and families who were involved in the foster care system.  Due to the impact she saw mental health had on the children and families she worked with Jamie moved over to the behavioral health field beginning her work at Central State Hospital.  Jamie began as a treatment team social worker and eventually served as the Social Work Director.  Jamie accepted a role at the Virginia Department of Behavioral Health and Developmental Services as a Community Transition Specialist over four years ago.  In this role, she works with the state psychiatric hospitals and the associated Community Services Boards/ Behavioral Health Authorities to focus on census management of the state hospitals, navigate access to the vast array of services and benefits across the spectrum of agencies, and support the discharge of individuals to appropriate community services, which allow the individual to live in the least restrictive and most integrated setting possible.  Jamie is passionate about working in the behavioral health field and finding ways to improve the lives of those who live with mental illness and the systems individuals interact with.

Asia Brown, LCSW 

Program Manager, CBCS

Pronouns: she/her/hers

Asia Brown is a Licensed Clinical Social Worker with a background in case management and quality improvement. Working for the Ryan White HIV/AIDS Program, Asia assisted numerous community members whose mental health had faltered because of stigma around mental illness and inequitable healthcare access. Looking to increase healthcare equity and community-based resource collaboration, Asia accepted the position as Program Manager for the High Utilizers of Virginia (HUV) Pilot in Northern VA. Asia leads a team of exemplary Community Health Workers, dedicated to providing clients with the guidance, support, and resources needed to help them remain stable and flourish in their communities.

Chris Douglas 

Pronouns: he/him

Senior Customer Success Manager

Chris Douglas joined findhelp in 2017 after 6 years in the education- and the health-focused nonprofit sector. A Senior Customer Success Manager specializing in Federally Qualified Health Centers, Primary Care Associations, and community collaboratives, Chris also helps universities and colleges, nonprofits, hospitals, health plans, and government offices leverage their findhelp tools to connect people with the social services they need. He has two cats and a garden full of succulents

Melissa Morales, LCSW

Senior Account Executive 

Point Click Care

Melissa Morales is a passionate clinician-at-heart healthcare leader. Trained as a Licensed Clinical Social Worker at the University of Southern California and practicing for over ten years, she leads network expansion in California for PointClickCare’s Acute & Payer Division, also known as Collective Medical. Melissa is a strategic thought partner who values care collaboration across the healthcare continuum and supporting innovative solutions for populations with social determinants of health.


Behavioral health conditions significantly impact costs of care—with studies linking behavioral health diagnoses with a 3.5x increase in overall care costs and up to a 103% increase in high-cost utilization.

While innovative health plans across the country are working to address these costs through programs tailored to support individuals with behavioral health conditions, patient engagement in these programs remains low. Without proper engagement, care costs for patients increase an additional 8-21%, and both behavioral and physical health outcomes decrease.

CBCS supports health plans across communities in achieving measurable cost savings for behavioral health patients by overcoming barriers to engagement and enlisting community resources to create unified, holistic solutions for improving behavioral health outcomes.

Addressing behavioral barriers to patient engagement

Patients with serious mental illnesses and behavioral health diagnoses, such as substance use disorder (SUD), traditionally have a high treatment dropout rate. In low-income communities this is even more prevalent, with studies showing that 45-60% of adult patients and 80% of adolescents with a behavioral health condition drop out of treatment before the minimal standard for treatment has been met.

The traditional healthcare system requires behavioral health patients to come into a clinic or login to a portal to receive appropriate care, failing to account for the unique socioeconomic and behavioral challenges these patients face. These challenges act as barriers to care, showcasing the need for health systems that both anticipate and address needs such as lack of transportation, means, or motivation in order to ultimately improve program engagement.

CBCS breaks down traditional engagement barriers by meeting patients where they are. 40% of CBCS patients have a mental disorder, 50% have significant substance use disorder, and many face additional social determinants of health which can make it difficult for health plans to reach them through traditional channels, such as phone or mail. As such, CBCS specialist teams instead leverage existing state and private Health Information Exchanges to be ready, 24/7, to meet patients in their moments of crisis and provide both the temporal and clinical support needed to move forward.

By willingly meeting patients where they are—whether at the emergency department, the home, or the McDonalds up the street—CBCS provides a convenient and trustworthy entry point for patients in entering the mental health care system, intervening and triaging moments of crisis to minimize acuity and improve patient outcomes.

Engaging community resources for improved outcomes

When we work within siloed healthcare systems, even the best behavioral health programs fall short by failing to engage with all stakeholders in a patient’s care cohort. Taking conversations outside clinical doors to include the community resources that patients are touching daily is key to holistic and long-term successful care management.

CBCS is a proven facilitator in bringing together community resources to create the care cohorts necessary for total patient care. For members with a behavioral health diagnoses, this could mean bringing together the local fire department, law enforcement, housing authorities, food banks, and shelters to discuss with the patient’s primary care physician, case manager, and therapist what outstanding needs the patient has—and how to troubleshoot a solution as quickly and effectively as possible.

As interdisciplinary teams across the medical and community neighborhood work together to support each other, patients feel cared for and collaboration increases as the unified effort allows all stakeholders to benefit from providing simpler, and more effective care.

Improving cost and clinical outcomes with CBCS

CBCS has proven the cost efficacy of its patient engagement methods—demonstrating an average 5:1 cost reduction rate within the first year of program implementation, and a 10:1 ROI upon subsequent years. And for organizations leveraging CMS or Biden funding grants, that return is even higher.

How? Improving clinical outcomes.

CBCS programs average a 45% reduction to ED visits and hospitalizations and a 41% reduction to no-show rates. In our SUD populations, opioid prescription utilization decreases an average of 30%.

These quick returns support healthy bottom lines for health plans by delivering high-impact results—at minimal upfront cost. All while ensuring high quality and affordability of care, at scale.


The American Public Health Association’s 2021 Annual Meeting and Expo will take place Oct. 24-27. The 2021 theme is “Creating the Healthiest Nation: Strengthening Social Connectedness.”

On October 27th, Dr. Enguidanos will be co-presenting COVID Response from Multiple Perspectives with the Cuban Society of Public Health, offering contrasting perspectives on the challenges faced in Cuba and the United States related to the management of COVID-19. Dr. Enguidanos will be presenting “An Overview of the U.S. COVID Experience.”

The purpose of the quarterly dialogues is to examine key public health issues in both Cuba and the U.S.  Through the leadership of their respective national associations (Cuban Society of Public Health and the American Public Health Association), the intent is to carry these conversations to the state/local level and engage with stakeholders who are critical to carrying out this work.

Co-organizers: Cuban Society of Public Health (SOCUSAP), Pennsylvania Public Health Association (PPHA), Public Health Management Corporation (PHMC) and American Public Health Association (APHA)



Enrique Enguidanos, MD, FACEP, MBA, CEO and founder of Community Based Coordination Solutions discusses how CBCS is rethinking the complex engagement model

It was the tenth time Mary had presented to the emergency department (ED) suicidal and intoxicated after trying to subvert her depression with alcohol. This time, a caring bystander had called 911 as they saw her laying on the sidewalk mumbling and the ambulance had brought her to the one place that was open after hours—the ED.

Mary’s story is not unique; research shows that roughly one in four Americans suffer from a diagnosable mental illness. When complicated by other psychosocial conditions such as substance abuse, homelessness, or chronic medical conditions, our country’s medical care system can be disheartening to navigate.  All too often, this leads to poor preventative care and eventually higher incidences of crisis events such as Mary’s. One term used to describe patients at such risk is “complex care patients.” Our current system of care for complex care patients isn’t working; a new approach is needed—one that accounts for these conditions and better leverages in-person connection to address them.

Read the full article here.

Keeping healthcare personal, scalable, and affordable with the CBCS direct patient engagement program

Trent was a Vietnam War veteran with diagnosed type 2 diabetes, PTSD, and acute schizophrenia who was seen frequently at the hospital with primary complaints of heart failure. When multiple tests showed that Trent’s heart was healthy, but that he was experiencing regular panic attacks, an onsite social worker sat down with him to explain that there are resources available to support veterans like him. However, even with those resources, Trent was unable to get the care he needed.

To get appropriate help, Trent needed to arrange transportation to and from the VA home—which required not only money to pay for the fare, but a phone to look up bus schedules or call for a ride. Trent also felt anxious visiting the home, unsure of who he would meet there or what he would experience. He would have to test his physical abilities to travel safely (especially in the winter when ice increased his risk of fall) and navigate new organizations with which he was unfamiliar. All of this became overwhelming—leading Trent and many others to stay at home, avoid connecting with key resources, and ultimately struggle with unmanaged conditions.

Changing this narrative starts with direct, personal, and supportive patient engagement programs that are designed to help individuals like Trent navigate the healthcare landscape, receive support during crisis moments, and ultimately connect with key community resources to improve their quality of life.

Step one: Supporting complex care patients in navigating the healthcare landscape

According to a recent study published by the Agency for Healthcare Research and Quality, merely five percent of the U.S. population accounts for over fifty percent of total healthcare spending—and one percent accounts for roughly twenty percent of healthcare spending. Of this spending, it is estimated that anywhere between 10 to 30 percent of this cost is avoidable—just factoring in high-cost utilization alone.

So why the high costs?

Patients with comorbid physical and behavioral health conditions require complex care that can seem impossible to manage—especially when current data shows that 30 percent of complex care individuals are homeless, 40 percent have some form of mental disorder, and 50 percent have significant forms of substance use disorder. As a result, many of these individuals struggle to know where they can turn for the care that they need and, like Trent, resort to an ED visit—knowing that it will be open and that they must be seen.

The CBCS direct patient engagement program works to address this gap, supporting those complex care patients where traditional care coordination programs have failed and providing assigned peer community workers who can help them navigate the healthcare system.

With the direct patient engagement program, workers reach out proactively to patients who are struggling—leveraging email, phone calls, texts, and in-person visits to connect with these individuals and work with them on achieving better care plan adherence. Whether that means helping the patient call and schedule appropriate follow-up appointments, going over medication instructions to make sure the individual understands the directions, or simply being the person who is willing to go with a patient to an exam to ensure they have transportation, language translation services (if needed), or other support, the engagement builds trust with the assigned peer—and rebuilds trust in a system that has traditionally overlooked these individuals or let them down.

Step two: Connecting with patients during moments of crisis

The peers assigned through the direct patient engagement program are available 24/7, allowing them to be there with the patients when the patient needs them most—reducing barriers to care and connection.

CBCS leverages existing shared community health information exchanges (HIEs) to receive real-time notifications whenever a patient presents at the hospital during a crisis, has a change in care plan, or needs other follow-up. By receiving updates in real-time, community workers can respond to immediate needs—providing ongoing, local, empathetic support to help rebuild that patient trust and ensure a smoother transition post-hospital discharge to post-acute, outpatient, MAT, or other follow-up care.

This 24/7 accessibility is key to successful engagement, as studies show that individuals with recurrent ED utilization are more common during evening and night shifts. This means that a majority of complex patients who would benefit from case management are presenting when there are no social workers or on-site community resources available, missing that opportunity for engagement and connection.

Ensuring that individuals will not only have someone available whenever crisis moments hit but have someone available who knows them personally and understands their circumstances becomes critical for improving transitional care and preventing future acute care utilization. As such, patients enrolled in the CBCS direct patient engagement program see an average reduction of $40K in acute care costs annually.

Step three: Bridging the gap between individuals and the communities ready to support them

The National Academy of Medicine suggests that medical care accounts for a mere 10-20 percent of a patient’s outcomes. That means it is not enough to provide quality medical care in traditional brick-and-mortar clinics, but that community resources are necessary to support these individuals in addressing social determinants that act as barriers to better health.

Encouragingly, the resources are out there. In fact, in the past year, multiple large-scale efforts have been made to strengthen community resources for marginalized patient populations, including:

  • $130 million from UnitedHealth and UnitedHealth Group to improve access to healthcare and housing for underserved populations—including a $5 million grant for addressing mental health
  • $50 million from Anthem to improve health equity
  • $25 million to address health equity and racial inequities

In other words, our communities are ready to support these individuals in addressing social determinants and improving their quality of life. However, even with the financial support, much of the U.S. is still struggling to move the needle in these communities.

Why? Because there remains a disconnect between these community resources and the individuals they were created for.

Erine Gray, CEO, and Founder of Aunt Bertha—a health IT platform that specializes in connecting individuals with community resources—explains:

“Just getting someone enrolled into a public benefit program, like SNAP, like Medicaid, like TANF, is incredibly challenging, and it requires a lot of policy knowledge… It was not that long ago that people would have to take the day off work and find childcare for their kids just to renew their food stamps or other public benefits. We need to build more dignity into the process of enrolling individuals to receive these benefits.”

CBCS brings together community resources for the most high-risk, complex care patients—with community workers who are trained to support individuals in connecting with public benefits and local and national nonprofits. In addition, these workers use immediate access funds—available through the direct patient engagement program—to meet emergent needs, such as transportation costs home from the hospital, dinner for a patient’s children, or adequate clothing to stay dry and warm during a recovery.

When these immediate funds are paired with community resources, they work together to streamline support efforts, reduce duplication of efforts between organizations, and ultimately ensure each individual has what is needed to be healthy and thrive.

Conclusion: We have all the pieces

At almost $12K spent per year per person on healthcare, and an average annual expenditure of $116,331 for those with complex conditions, the solution to improving care is not in getting more. It is connecting more.

As more organizations learn to invest both money and time into supporting complex care patients like Trent with direct patient engagement programs, the return on those investments is steep: millions of dollars in cost savings for payers, ED and opioid use reduction for patients, and better alignment and satisfaction for the communities as a whole.

The cost and health benefits of the direct patient engagement model

The healthcare system is difficult to navigate, and for individuals with underlying psychosocial issues like mental health diagnoses, substance use disorder, homelessness, or other social determinants of health, it becomes even trickier.

Many of these individuals face challenges traditionally stigmatized by the healthcare system—leading them to feel distrustful of providers or unsure of where they can turn for help. They may resist engaging in the basic and/or preventative care needed for their underlying conditions, which then slowly exacerbates their status until a crisis event occurs, leading to ED utilization, and subsequent admissions.

Breaking this cycle requires fundamentally changing the way we approach patient engagement—utilizing engagement specialists that can rebuild trust, change patterns, and ultimately improve outcomes.

Current barriers to patient engagement: establishing trust

“Mary” had a history of alcohol abuse, often showing up to the emergency department suicidal and intoxicated as she strove to subvert her depression with alcohol.

Mary was enrolled in the CBCS high utilizer program, and staff began trying to contact her. However, the phone number on file was invalid, as was the address. Through the regional Health Information Exchange tool, CBCS was able to contact her during her next ED visit.

By meeting her in person, CBCS staff was able to describe the program and begin to establish trust. While it took ten visits before she trusted them enough to initiate talking with staff about being “ready” to work on recovery, over the following months they worked together on detoxification, recovery, housing, and job placement issues. After several months, she became an advocate within the outreach program!

Mary has reiterated how persistence in contacting her during each ED visit is what eventually led her to agree to “give [CBCS] a chance”. It was through direct patient engagement that Mary overcame her distrust after years of dead-ends and frustrating encounters that focused primarily on very partial treatments based on provider perceptions. She felt that if CBCS were continuing to reach out to her time and again during moments of crisis, it was a resource she could depend on to support her in addressing her issues.

As Mary’s story demonstrates, successful patient engagement for our most challenging complex patients requires being available to help, to listen, 24/7, and address issues with effective treatments.  We need to become the “round-the-clock specialists” trained to work directly with complex care patients in addressing social determinants.

Social determinants as a specialty

Referring patients to specialists is a common practice within the medical field. While a primary care physician wouldn’t think twice about referring a patient with a complex heart condition to a cardiologist, physicians often feel the need to address social determinants themselves without adequate training to do so.

The CBCS direct patient engagement program provides specialists in community engagement that can work alongside patients to address social determinants and improve health. Each team member is trained to work with marginalized populations—helping these individuals overcome stigmas they face in connection to homelessness, substance use, incarceration, or other traditionally overlooked issues.

Because most crises fall outside traditional working hours, but require immediate intervention for resolution, CBCS’s direct patient engagement team members are available 24/7 to connect, support, and engage individuals—whenever they need it.  By meeting with patients when they are most vulnerable—often during crisis moments and in the ED—our care teams can more effectively establish that trust and credibility so that, next time a crisis hits, the patient knows who they can call.

Finally, outsourcing engagement for patients with complex conditions frees up physicians to spend their time on what they do best—solving complex medical problems for better care—and leaves solving for societal needs to those who have the bandwidth and community connections to most effectively address them.

The clinical and financial benefits of the direct patient engagement model

As patients are provided with an advocate to help them navigate our nation’s healthcare system—while building rapport and trust—costs are reduced, and patient outcomes improve.

National data suggests that roughly two percent of patients account for 25 percent of healthcare dollars spent, and five percent of patients account for almost fifty percent of our nation’s healthcare spending. While some of this cost can be attributed to treating costly conditions—like chronic kidney disease and diabetes—much of it comes down to unnecessary acute care costs resulting from unmanaged chronic conditions and social determinants of health.

For example: the average patient with complex care needs costs the healthcare system between $60,000 and $100,000 annually in medical costs (admissions, ED utilization, prescriptions) if they have between five or six visits a year. When factoring in social determinants common to individuals with psychosocial issues—including frequent need for law enforcement, time spent in the prison system, or utilization of ambulatory services—that number increases.

Implementing direct patient engagement programs can reduce costs by 20 percent a year—or four to five times the initial implementation investment—by reducing that unnecessary acute care and connecting patients to the community resources that help address the other social determinants impacting health and utilization. CBCS patients enrolled in the direct patient engagement program experience, on average, a 50-60 percent reduction of ED visits, and reduce opioid prescriptions by 20 percent.

When we tailor our programs to be patient-friendly, they become provider-friendly, too. Physicians partnering with CBCS for direct patient engagement programs have reported lower burnout and higher job satisfaction—with one physician stating the program motivated him to postpone retirement another ten years as he was able to get back to doing what he did best: caring for the medical needs of each individual. It’s a win-win.



“Even if you’re thirty years sober, the condition doesn’t go away.” 

I first met Terrance in a secured state prison. He was nearing the end of his sentence, and I was meeting with him and his case manager before he would be released the following week.

Terrance had originally been arrested on a drug-related charge, and although he had been sober for the duration of his prison sentence, the call of his addiction was never far. Terrance’s care coordinator in the prison had reached out to us to help ensure that—once Terrance left the system—he would still remain supported.

The high cost of the War on Drugs

The War on Drugs, officially declared in the seventies, has led to the mass incarceration of individuals like Terrance.  For over five decades this war has played out—always with politically charged directives but with rarely with the required focus on the individual stories of substance abuse, addiction, and the consequences of both.

Some argue that providing appropriate SUD care is too costly—a close look at the data indicates that nothing could be further from the truth.

The cost of a comprehensive approach to SUD programs that includes acute and outpatient care, Medication Assisted Treatment (MAT), and longer-term support groups is miniscule in comparison to the cost of incarceration. Data shows that the U.S. government spends an estimated $9.2 million per day on incarceration of drug offenders. In addition, the National Drug Intelligence Center estimates that drug use causes society as a whole $193 billion a year—$113 billion of which is associated with drug-related crime.

And how do we put a cost on the loss of human lives?  More Americans died in 2017 of drug overdoses than the total number of casualties from the Vietnam War. Of these overdoses, 68 percent were caused by opioid abuse.

Never truly free: the chains of addiction

Roughly 65 percent of individuals in jails or prisons across the U.S. struggle with some form of addiction. Yet research conducted in 2010 by the National Center on Addiction and Substance Abuse at Columbia University suggests that only 11 percent of individuals in our criminal justice system receive any treatment for their SUD.  And the trend is actually worsening— a 2019 study by the National Academy of Sciences showed that only 5 percent of inmates with opioid use disorder received specific opioid-related treatment.

This lack of treatment could be a result of the common misconception that sobriety means we’ve won the batter over addiction. In reality, the early recovery stage of addiction can last up to a year, and post-acute withdrawal symptoms (PAWS) can last even longer.

After a sober prison sentence, individuals may experience drug cravings for months or longer.  This is a critical period—arguably THE critical period—in which support can translate into long-term success.

Typically, the immediate post-incarceration period results in gaps in SUD support just at the moment individuals need this support most to have any chance for a successful transition into community life.  Without appropriate SUD support during this period, individuals may be momentarily free from the penal system, but they remain prisoners to their addictions—never truly being free of either the cycles of incarceration or addition.

Appropriate SUD support upon release from incarceration is critical to breaking the cycles of addiction and incarceration that permeate our society.  We CAN win this war, but only by understanding and addressing these dynamics through the funding of programs that effectively provide this support.

Widening access to Medication Assisted Treatment and other SUD supports

Until the Affordable Care Act, costs associated with SUD (and behavioral health) were not supported by Medicare or Medicaid. Since then, great efforts are being made to expand the substance use disorder support available—including the decision by CMS earlier this year to reimburse the cost of approved opioid treatment programs.  Still, there’s room for improvement.

Federal, state, and local governments spend a combined $74 billion annually on SUD-related court hearings, incarcerations, and paroles.  Only $632 million of that money is spent on actual SUD prevention and treatment.  THAT’S LESS THAN 1 PERCENT!!! 

If an appropriate portion of that funding were reallocated to the actual treatment of SUD—rather than its criminalization and punishment—we could improve the care addicted individuals receive AND dramatically reduce the financial and human costs of SUD on society.

Data from the National Institute on Drug Abuse shows that every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft.  When healthcare-related savings such as reduced acute and ED care are also factored in, savings jump up further to $12 for every $1 spent! And—most importantly—individuals are finally getting the support they need to leave behind addiction for good.

What we can do as payers and providers? 

Ideal post-incarceration SUD care involves coordinated community-wide participation.   Appropriate resources for housing and post-incarceration job support yield significant dividends and dramatically increase the success rates of SUD program efforts.  Coordination with local law enforcement and corrections efforts all point to long-term community success, as do dedicated coordination between local hospitals, clinics, and Emergency Medical Services.

When communities offer such a coordinated approach, care teams can assure former inmates have access to the medical care they need from day one of their new life.   Indeed, when working with care coordinators in the prison system to meet with individuals like Terrance, significant work can be accomplished prior to release from incarceration.  Case managers can establish a primary care provider, enroll the individual in Medicaid, and arrange transportation to and from medical appointments.  In addition, we can collaborate with prison system coordinators, outside case managers, primary care providers, and MAT facilities to establish a seamless plan for recovery to support.

A collective responsibility

Providing the resources necessary to better support individuals with SUD post-incarceration is critical to breaking the cycle off addiction and incarceration—and ending this fifty-year War on Drugs.  This is a shared responsibility.  By placing the patient at the center of the “wheel-of-care”, we can better understand how each of us contributes in our own way as an additional spoke to support that center and keep the wheel moving forward.

Patients move forward when we bring all key parties to the table—supporting patients with our time, attention, and financial resources. As primary care providers, payers, and MAT facilities, we bring our individual spokes together to support those of behavioral health organizations, local law enforcement, and community resources offering transportation, housing, and food security. Non-profits, support groups, and employment specialists can be brought in to further support patient progress.

Together, the efforts and resources of all members work to propel patient progress and keep the wheel moving on the path to recovery.

We have to move beyond dialogues on political ideologies and improve our focus and support for patients like Terrance as they leave our prison systems.  By providing him with sufficient resources– the right spokes – his wheel begins to turn.  And only as Terrance’s wheel turns do we all move closer to victory in the war on addiction.

**This article is provided through a collaborative effort with Collective Medical and is originally published on Becker’s Hospital Review HERE. It was written by Dr. Enrique Enguidanos, CEO and Founder of  CBC Solutions and practicing ED Physician.