Case Study: Mat-Su Health Foundation

Improving outcomes in high-risk populations

Patients with high-risk behaviors need more than standard medical care can offer to address the underlying social determinants that impact overall health. By adopting a holistic community-based approach through CBCS, the LinksSocial Services program—funded by the Mat-Su HealthFoundation—achieved significant results in improving patient outcomes and bottom-line cost.

Background: Understanding the Social Determinants of Health

Social determinants of health have a significant impact on patient care, affecting an estimated two-thirds of patients and accounting for roughly 80% of a patient’s outcomes.

At the Mat-Su HealthFoundation in Wasilla, Alaska, external programs and partnerships were put in place and funded to help address these social determinants. In addition, because many of these patients had comorbid behavioral health diagnoses, special resources—including a behavioral health crisis intervention team—were made available to address comorbidities.

As patients frequented the emergency departments, they were referred to these additional services, but few patients followed through. As a result, providers and social workers found that patients were instead relying on 911 and emergency services rather than participating in the specialized programs and getting proper care at a lower acuity level.

Solution: Creating something better, together

Looking for a way to improve the effectiveness of community programs, the foundation partnered with Community Based Coordination Solutions (CBCS) to develop the High Utilizer Mat-Su (HUMS) program—a community collaborative program utilizing the CBCS Direct Patient Engagement program to support high-risk populations by bringing together medical, behavioral, and community resources to provide critical care and address social

Download the full case study here to learn how by partnering with CBCS, Mat-Su achieved an average 57% reduction in ED utilization, a 47% reduction in opioid prescriptions, and over $4 million in savings over two years.

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Caring as Communities Podcast: Respite Care

Medical respite care tries to bridge the gap for homeless men and women who are too sick to be on the street or be in the shelter, but not sick enough to need to be in the hospital.

Dr. David Munson, Boston Health Care for the Homeless Program, and Andy McMahon, Vice President, Health and Human Services Policy UnitedHealthcare Community & State, discuss how to implement successful respite programs in this episode of Caring As Communities.

This podcast is now live on AppleSpotify, and a number of other smaller platforms as well. A transcript of the podcast can be found, along with the audio, on our hosting platform, Buzzsprout. 

Additional Resources from this episode: 

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Caring as Communities Podcast: Solutions for Homelessness

Homelessness remains a key issue for over half a million people in the US each year, with the pandemic and subsequent unemployment leading numbers to climb.

Join our guests Rob McCann, CEO of Catholic Charities of Eastern Washington, and Damian Mazzotta, Founder, and Chairman of The Shower of Hope, and learn what communities like Spokane and Los Angeles are doing to address this in our most recent podcast. This podcast is now live on AppleSpotify, and a number of other smaller platforms as well. A transcript of the podcast can be found, along with the audio, on our hosting platform!


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Caring as Communities Podcast: Addressing Homelessness & Healthcare

The COVID-19 pandemic has highlighted shortcomings in our systemic approach to homelessness. Join Dr. Jim O’Connell, Founder of the Boston Health Care for the Homeless Program, and Bobby Watts, MPH, MS, CPH, and CEO, National Health Care for the Homeless Council as they discuss what needs to happen at local, state, and federal levels to better house and care for the health of these vulnerable individuals.

This podcast is now live on Apple, Spotify, and a number of other smaller platforms as well. A transcript of the podcast can be found, along with the audio, on our hosting platform!

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Addressing Racial Disparities in Health: Part 2 – Racism in Healthcare Today

The second in our series, Racism in Healthcare Today, has dropped! It’s available on AppleSpotify, along with a number of other podcast stations. A transcript of the podcast is available for our friends in the deaf community on our main platform,  

Listen today!


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Podcast Episode 6: Addressing Racial Disparities in Healthcare- Part 1


Listen to Part 1- The History of Racism in Medicine on Apple and Spotify !

Additional Resources:

Dr. Terralon Knight:

Maryland Sickle Cell Disease Association

Knight Coaching:

Dr. John Vassall: 

Northwest African American Museum

  • How to be an Anti-Racist, Ibram Kendi
  • Caste: The Orgins of Our Discontent, Isabel Wilkerson
  • Hillbilly Elegy: A Memoir of a Family and Culture in Crisis, J.D. Vance

Dr. Kellee Randle

The Mama-Pikin Foundation

Equity Plus Ventures

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Caring for Communities Podcast: The Opioid Epidemic and Facilitating Better Medication Assisted Treatment
Although the opioid epidemic has been a rising concern for years now, the solutions available for those struggling with substance use disorder are slow to follow. Increased regulation about Sensitive Information—combined with the stigma of addiction—has posed unique challenges in the field of Medication Assisted Treatment.

Listen in as Dr. Enrique Enguidanos interviews Drs. Eric Ketcham and Gregg Miller to discuss what can be done to improve the MAT care available and key strategies for addressing the opioid epidemic.

Special Guests: 

  • Eric Ketcham, MD, MBA, FACEP, FASAM, FACHE, and Emergency Physician & Addiction Specialist at Presbyterian Healthcare Services
  • Greg Miller, MD, FACEP, Chief Medical Officer at Vituity


  • Dr. Enrique Enguidanos, CEO/Founder of Community Based Coordination Solutions, and practicing Emergency Physician in Seattle

Listen to the podcast on Apple and Spotify !

Additional Resources Available for this episode:

SAMHSA (Substance Abuse and Mental Health Services Administration):

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Catalyst Program 2: Implementing Customized Care Plans

Catalyst Series Part 2: Implementing Customized Care Plans

Customized Care Plan Development and Emergency Department Relations are integral components of every Complex Care program. As medical professionals, we know the importance of reducing future re-admissions and a solid care plan is crucial for our high resource patients. A care plan should enhance the patient’s treatment plan by providing a list of identified health conditions or problems with a corresponding prioritized list of interventions to meet the patient’s goals.

Typically, this is a 4-month project with our clients. CBCS develops care plans with an emphasis on:

  • Input from patients, providers, and pertinent community resources
  • Input from patient’s recent ED visits and/or admissions
  • Focus on end-user effectiveness
    • Emergency department, admission, and out-patient providers
  • Timely and effective care plan updates
  • Medication reconciliation
  • Recommended actionable items for end-users
  • Upcoming patient appointments and/or current treatments
  • Key triggers such as violence warning

CBCS also promotes care plan recognition and use within the community by meetings and the education of target community resources such as emergency department staff, hospitals, and hospital-based care coordinators, outpatient providers and their staff, regional behavioral health and chemical dependency centers, and other pertinent resources as identified.

By focusing on the individual patient and ensuring their needs are identified and addressed within a Customized Care Plan, re-admission rates go down, and therefore so does the cost to the healthcare system. A win-win for everyone!

Join us next time as we discuss our Controlled Substance Management Program and how it helps identify substance abuse issues specific to your community and what you can do to improve this complex care issue.


Those of us working in the Complex Care community have pain points—areas within our systems that, if functioning better, would work better for our high-utilization clients, our staff, and our bottom lines. With this in mind, CBC Solutions (CBCS) has crafted five (5) individual programs that can help target what we have found to be the most pressing issues that once solved will make a big impact. Learn more here:


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Podcast Episode 4: Substance Use Disorder in the Wake of COVID-19

An analysis of hospitals on the Collective network shows that overdose visits as a proportion to overall emergency department visits have increased by about 35 percent since lockdown began across the nation.

Join CBC Solutions’ CEO and Founder, Dr. Enrique Enguidanos, and Kat McDavitt, Chief of External Affairs at Collective Medical, as they interview Anne Zink, MD, FACEP and Chief Medical Officer for the State of Alaska and Hon. Nathaniel Schlicher, MD, JD, MBA, FACEP, Regional Director of Quality Assurance for Franciscan Health System and Associate Director of the TeamHealth Litigation Support Department.

Key topics:

  • Obstacles to patients receiving substance use disorder treatment
  • Silver linings coming from the pandemic
  • What it takes to implement a successful SUD program

Listen to the full episode here, on Spotify, or Apple Podcasts.

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5-Part Catalyst Series: Community Multi-Disciplinary Team

5-PART CATALYST SERIES: CBC Solutions Introduces 5 Complex Care Catalyst Programs

Relieving Your Complex Care Community Pain Points One Program at a Time

Those of us working in the Complex Care community have pain points—areas within our systems that, if functioning better, would work better for our high-utilization clients, our staff, and our bottom lines. With this in mind, CBC Solutions (CBCS) has crafted five (5) individual programs that can help target what we have found to be the most pressing issues that once solved will make a big impact. The five programs target the following topics:

  • Community Multi-Disciplinary Team
  • Customized Care Plans
  • Controlled Substance Management Program
  • Community Resource Engagement
  • Direct Patient Engagement

We begin our five-part Catalyst Series discussing the importance of the Multi-Disciplinary Team (MDT) and how CBCS works with your team to improve this component within your current system of complex care.

The development of a strong multi-disciplinary team (MDT) is an integral component of CBCS’s community-based high utilization program. Generally, high utilization clients need help from many resources in the community.  By engaging them in a common approach to client care it serves multiple purposes:

  • Clients get the care they need faster as many resources involved in their care work together towards seeking their ideal outcomes
  • Community care becomes more efficient as the multiple resources involved in high utilization cases begin to better understand each other’s capacities and limitations, and more effectively work together towards the most effective approach to care
  • Improved cost of care as resource utilization amongst involved entities is streamlined

When working to develop your MDT with CBCS, we will be typically on-site for 2-3-day periods each month. During the first month our focus will be on:

  • Identifying the community needs and resources most affected by high resource clients, and engaging them in participation in the MDT program
  • Working with the contracting agency to identify the appropriate program patients
  • Working with the contracting agency to identify the assigned program staff member, and begin training them on MDT administration

Once assembled, the MDT group will begin meeting in month two.  Meetings are typically 90 minutes long and involve a review of about 5 patients per meeting; short updates on previously reviewed patients also occur. Typically, by month four assigned staff should be able to run the MDT program by the end of the six-month contract period. In addition to monthly on-site visits, CBCS staff will meet with assigned program staff for weekly teleconference meetings, and via phone and/or additional teleconferencing as needed.

MDT membership varies depending on community needs; core members are typically representatives from local emergency departments, large primary care groups and/or FQHCs, EMS organizations, and behavioral health and substance abuse treatment centers. Ad-hoc (invited as needed for specific cases) members may include representatives from therapeutic court and legal systems, jail/prison programs, housing authority groups, law enforcement agencies, and others. CBCS encourages contacting entities to submit patients for enrollment into the MDT program that they have found to be particularly difficult to engage, and/or have difficult case management histories.

Join us for the next entry in our Catalyst Series where you will learn the importance of Customized Care Plans and how their implementation will help improve your Complex Care programming.

To learn more about all of our Catalyst Programs, click here!


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