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Do you feel like you are swimming upstream with a small paddle when it comes to integrating social services into your medical care system? If so, you are not alone. Despite a desire by the medical community to address the social determinants of health in order to improve patient outcomes, limited progress has been made in integrating social services with medical care.

A recent Health Affairs article addressed this very issue and we felt that we should share it with you.

The article, emphasizing the relationship between social factors and health outcomes, data from multiple “early adopter” ACO’s (all of which were identified as having an emphasis on addressing social determinants of health needs), found significant difficulties integrating social services with medical care, with three major themes identified as limiting their efforts:

  • Lack of social needs data being used in decision-making
  • Difficulties developing partnerships between ACOs and community-based organizations
  • Difficulties identifying approaches to delivering ROI when implementing program innovations

These findings are consistent with our experience at CBCS and have driven much of our innovation and operations. Our relationship with Collective Medical has repeatedly demonstrated the value of real-time data in driving community improvements and promptly addressing health needs. Our programs are centered around community-based relationships and operations and have proven to deliver significant ROIs within months of implementation and we can help you with addressing these difficulties.

Are you ready to improve patient outcomes? Contact us today!

Click HERE to read the Health Affairs article.

 

*This article is written by CBCS Founder, Enrique Enguidanos, and is a re-post from Becker’s Hospital Review that ran on April 29, 2020.

Earlier this year, communities around the world engaged in a collective movement called “social distancing”. Schools and offices shut down as the world went virtual and individuals and families committed to isolation in hopes of limiting the spread of the COVID-19 virus.

But this idea of using social circumstances to affect physical health is not a new concept. The impact social interactions and situations have on the medical world goes beyond preventing infectious disease and can actually significantly improve a patient’s well-being when the right resources are in place.

Understanding Social Determinants of Health

Social determinants of health affect 80-90 percent1 of a person’s health outcomes and one-fifth2 of all Americans are living in environments that compromise their health. (And no… I don’t mean the busy coffee shop where someone is likely to pick up a pandemic-causing virus).

These Americans are living in situations where they lack access to housing, education, public safety, proper healthcare services, transportation, or job opportunities. There are neighborhoods where crime rates and residential segregation are so prevalent, zip codes have become a stronger predictor of overall health than both race and genetics3. And if we’re ever going to truly help these patients, we have to address the things that affect them outside hospital doors.

CMS Interoperability—A Step, Not a Solution

As an ED physician, I hear the word “interoperability” now almost daily as this month’s most trendy buzzword. The recent CMS rules on interoperability are breaking down traditional silos between hospitals, post-acute facilities, primary care physicians, and others—so that when patients leave my care in the hospital, the next provider to care for them will have exactly the insights needed to ensure a smooth recovery.

Grateful as I am for this progress, I’d like to argue that these rules are a step—and not a solution—in providing better care for our vulnerable patient populations.

Interoperability is only as effective as the people it connects. Traditional healthcare teams alone represent a small percentage of what impacts a patient’s wellbeing. For interoperability to be effective, it has to facilitate communication beyond the boundaries of traditional healthcare into the communities that these patients call home.

Stepping Outside Traditional Medical Community

When I founded Community Based Care Solutions, I wanted to close the gaps I saw in traditional healthcare models. I recognized that while hospitals, health systems, and health plans work to care for the unique needs of each patient, without the insight and support of a community care team their effectiveness is limited and may come at a high financial cost.

Our social workers have been able to see the power interoperability facilitates using a real-time, ADT-based care collaboration platform—Collective Medical. The platform’s notification system sends messages directly to our case managers, letting them know where their patient is, so they can meet the patient at the point-of-care and proactively work with that patient to connect him or her to the right resources for optimal care—despite any challenges posed by existing social determinants.

For example, half4 of state and federal US prisoners have a reported chronic condition—including cancer, heart-related problems, diabetes, kidney problems, arthritis, asthma, and others. When these individuals leave the prison system and return to civilian life, their transition from correctional healthcare to traditional healthcare systems is often difficult and results in their condition worsening, leading the individual to seek otherwise preventable emergency care.

When case managers are notified and able to work with a patient—in the prison and before release—to complete appropriate Medicaid paperwork, set up and arrange transportation for needed follow-up visits with a traditional PCP or specialist, and ensure housing has been squared away, the patient’s outcomes improve significantly.

Meeting the Homelessness Crisis

Over the past two years, homelessness has been rising, reaching over an estimated 560,000 last year.5 Of these individuals, roughly 40 percent visit the ED at least once a year, with 8 percent accounting for 54 percent of all visits.6 This is due largely to their unstable living situation and the health conditions those conditions cause or exacerbate.

Including housing resources as part of the interoperable care management system can significantly reduce ED utilization for patients experiencing homelessness and lead to better long-term outcomes. With interoperable homelessness support systems, our case managers know where patients are going, confirm that they have a living situation suitable to any existing chronic conditions, and maintain appropriate follow-up contact for continued health.

While finding long-term housing arrangements can be challenging, even small changes can be a great start. For one of our clients, simply negotiating four guaranteed respite beds within a local shelter saved $3 million in unnecessary ED care within one year.

The Right Direction

While we have a long way to go in obtaining true interoperability between all needed parties, the CMS rules allow us to make a step in the right direction. Starting small, and growing the programs as we learn, will get us where we need to go more quickly and effectively than waiting for the day when we magically have a solution for all the complexities of patient care.

As we do what we can, recognize shortcomings, and strive to address social determinants—we will be able to not only improve the medical care given, but the lasting outcomes thereof. And the progress we see in our patients, our hospitals, and our communities will improve exponentially.

Dr. Enrique Enguidanos has over 20 years of clinical experience in Emergency Medicine—much of which has been spent also serving in organizational and systems management roles. As CEO of Community Based Care Solutions and a practicing ED physician, he has spent over a decade developing and fine-tuning systems of care and community management systems that have proven very effective for frequent utilizers. He has organized these systems in a manner that allows CBCS to continuously reproduce care results across varying communities and health care systems.

1 https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five/
2 https://www.healthaffairs.org/do/10.1377/hblog20150806.049730/full/
3 https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
4 https://www.bjs.gov/content/pub/pdf/mpsfpji1112.pdf
5 https://www.statista.com/statistics/555795/estimated-number-of-homeless-people-in-the-us/
6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447161/

It’s been difficult to keep up with the rapidly changing information and community dynamics experienced by the COVID-19 pandemic.  As an emergency physician based in Seattle, WA, our CEO, Enrique Enguidanos has witnessed first-hand the strain on medical and community resources.

Two major risk factors were quickly identified as showing higher COVID-19 mortality rates – pre-existing health conditions and older age.  Early recognition of these has helped communities in triage and allowed for effective allocation of strained community resources.  A third cohort of society has recently been added to that high-risk cohort – low socioeconomic status.

Check out this recent article from The New York Times, which highlights how this can be of particular concern amongst our communities.

Community Based Coordination Solutions (CBCS) encourages all healthcare leaders to pay particular attention to the higher risk of COVID-19 amongst those of lower socioeconomic status, homeless, those suffering from chronic medical conditions, and those with issues of substance abuse or mental health.  Given our expertise with rapid mobilization of effective resources for these high-risk groups, we want to extend an invitation to engage in dialogue about the possible options available to communities to mitigate the risk of COVID-19 progression for this community cohort.  Our CEO has extended the following invitation: “I am available for dialogue, free of charge, anytime over the next few weeks – just send me a note if I can help!” He can be reached directly at Enrique@cbc-solutons.org, or feel free to fill out our contact form and we will be in touch ASAP.

Coordinating Care for Vulnerable and Complex Patient Populations

Community Based Coordination Solutions (CBCS) works with at-risk entities—such as insurers, health systems, accountable care organizations, managed care organizations, and health foundations—to coordinate the care of patients with complex care needs. Many of their patients have comorbid conditions, including substance use disorder and mental illness and social determinants of health that require special care.

The Challenge: Controlling Costs for Patients with Unique Care Needs

For complex care patients, the care needed often exceeds what can be reasonably provided within the emergency department and/or hospital walls. Approximately 30% of these patients struggle with homelessness, 40% struggle with substance use disorder (SUD), and 50% have some behavioral health diagnoses. Many of these patients face more than one social determinant of health issue simultaneously, and some struggle all three of the above.

Without appropriate care, these conditions will go untreated, leading to a costly and unending cycle of ED utilization. CBCS works with at-risk entities to create better community care coordination patients within the top 2-3% of utilization, with a goal of reducing and preventing utilization by connecting these patients with the care they really need. As patients are connected to strong resources outside the ED, patient outcomes improve, leading to fewer unnecessary ED visits and readmissions and the associated reduction in cost. Dr. Enrique Enguidanos, CEO and Founder of CBCS and practicing Emergency Physician in Washington, explains:

“Vulnerable patients often turn to the ED when psychosocial crisis occur and they feel they have nowhere else to go; in such instances, they would be better served by a community-based team and care plan that’s designed to meet their individual needs. Hospitals, health systems, health plans, and other entities that are trying to care for the unique needs of these complex patients— but without the insight and support of a community care team their efforts are limited, and come at a high financial cost. This is when providers and payers need additional help to control costs and strengthen care for their patients.”

The Solution: Working Proactively with Patients in Real-Time to Direct Care

Working as an ED physician, Enguidanos understood the urgency required when caring for these patients. When a patient presented at the ED with an opioid overdose, suicidal following a psychotic episode, or hungry and ready to be off the streets, the patient needed access to appropriate care connections in that moment—not days or weeks later.

CBCS implemented Collective Medical, a care collaboration platform designed to connect care teams across medical neighborhoods through real-time patient notifications and care guidelines. With the platform, CBCS case managers receive real-time notifications when one of their patients present to the ED, allowing the case manager to meet the patient in the hospital and work with appropriate care team members to determine the next steps of care.

Along with meeting patients at the point of care, coordinating with others has been crucial in helping these vulnerable patients. Creating cohorts within the platform, case managers are able to bring ED physicians, primary care and specialty physicians, social workers, pharmacists, and key community members together to collaborate on patient guidelines and determine what can be done to best help each patient. Enguidanos explains:

“As we bring both those who will provide the care and the entities that will pay for it to a table together, we’re able to create plans for these patients that not only reduce unnecessary spending but genuinely improve the care each patient is being given. As we focus on these individuals, rather than increasing cost and complexity, it actually simplifies care by ensuring each patient goes to the best resource for his or her needs the first time and receives a continuity of care across care teams.”

Outcomes and Patient Stories

By bringing the care community together to coordinate care for these patients, outcomes improve—both for individual patients and for groups as a whole.

Patient Story: “Ken”

When Vietnam War veteran, “Ken” was referred to CBCS for case management, he had over 200 visits within two years across hospitals. The case manager began receiving notifications whenever Jim was in the hospital and made a point to meet him at the ED or follow-up shortly thereafter. The increased follow-up led to a 50 percent reduction of readmissions within one year.

With each visit, the case manager noticed a trend—Ken was struggling with post-traumatic stress disorder (PTSD). When his PTSD became unmanageable, he would turn to the hospital, often presenting ten or more days in a row wanting to talk with someone. When the symptoms subsided, he could go up to two months without a hospital visit.

The case manager met with hospital care teams and local resources to determine a plan for Ken. It was decided that someone from a community support resource for veterans would call Ken twice a week to check-in and talk with him. During these calls, a member of Ken’s care team could gauge how he was feeling and watch for triggers or patterns that might suggest his PTSD was becoming unmanageable. If things started to get bad, the care team member would have the appropriate resource reach out to follow-up with Ken at home.

With a care guideline in place to address his behavioral health needs, Ken’s ED utilization decreased by 50%.

Organizational Outcomes: The Mat-Su Health Foundation

The Mat-Su Health Foundation—a non-profit organization set up to support the health of the people of Mat-Su, Alaska—was looking for a way to support its “High Utilizers of Mat-Su” (HUMS) program. Partnering with CBCS, it relied on improved communication through real-time notifications and collaborative care to track and help these patients, achieving a 61 percent reduction in ED visits and a 20 percent reduction in opioid use.

This ultimately saved Mat-Su several million in unnecessary care costs, and improved community satisfaction.

Overall Outcomes: Breaking the Cycle of Addiction and Utilization

Depending on the area, CBCS will partner with a number of different resources—including those outside the traditional care continuum. Law enforcement and correctional facilities, EMS services, housing authorities and food banks, chemical dependency services and more all come together with one platform, bringing unique insights that lead to a custom-tailored care plan for each patient.

CBCS patients with these collaborative care plans see, on average, a 50-60 percent reduction of ED visits—while breaking the addiction cycle in the process.

The organization continues to expand its collaborative efforts to improve care for these vulnerable patients, including addressing social determinants of health, behavioral health, and complex chronic medical diagnoses.

Advocates for Change: “Beth’s Story”

When “Beth” was referred to CBCS for case management, she was sleeping in her car. A wife, mother, and successful business owner, she lost everything—including her business—after her divorce. She turned to alcohol, and that turned into a substance use disorder.

A CBCS case manager met Beth in the hospital every time she presented, often with dangerous blood-alcohol levels, but Beth wanted nothing to do with any of the programs offered. Finally, on the tenth visit, she accepted help.

The case manager was able to put Beth up in a hotel for two days while they waited for an opening in the detox facility, then helped Beth get the clearances she needed to complete the nine-day detox and move to a rehabilitation facility. Upon successful completion of both, Beth was released and continued to attend regular community meetings. Her case manager worked to get her into temporary, and eventually permanent, housing and employment, and Beth became proactively involved in her community meetings as a mentor for those patients currently struggling with SUD.

Beth eventually graduated from the program and went to work with CBCS as a powerful advocate for change—approaching her patients with empathy and hope.

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*This Case Study was written by our exclusive IT partner, Collective Medical. 

One of the pillars of a strong community-based resource coordination program is the use of a common real-time data platform across the community of care. CBC Solutions exclusively partners with Collective Medical platform to help our clients accomplish this.

Throughout our country organizations have been engaging in valuable health improvement programs for years. Often, these are implemented with very little or no communication with other community stakeholders. As a result, most communities have vast duplication of certain efforts, limited knowledge of the gaps in care delivery that exist across their community of care, and where the most effective opportunities to address these gaps exist. To effectively address these limitations in resource management, communities must implement some form of “common shared language” to be used for their primary stakeholders.

An article from Health IT Analytics highlights some of the benefits seen with the implementation of the Collective Medical real-time data platforms implemented throughout the state of Oregon in 2015. The article also highlights the benefits experienced at CHI St. Anthony’s Hospital with regard to reductions amongst the ED visit and hospital admissions rates for complex high-medical-utilization patients.

We have over a decade of experience working with the Collective Medical platforms and have certainly found this to be the case in every community in which we’ve used their tools. But the benefits of such a strong real-time data platform are not limited to hospitals. Given that the platform engages stakeholders across the community of care, from hospitals to out-patient clinics to other important community resources. It provides a common-language approach for all stakeholders to interact in a common approach, allowing for much more effective care delivery and more effective utilization of our precious health care resources.

 

 

High utilization clients struggle with a unique set of challenges, and most have experienced more than once societal difficulties obtaining prompt and effective solutions to these needs, especially on an emergent basis. While their psychosocial stressors pose some extraordinary challenges, they also provide some unique engagement opportunities. Staff can make tremendous in-roads with clients when they identify needs that can be immediately addressed.  Granted, clients rarely have one single issue causing all of their high resource utilization. But it is not uncommon for staff to be able to identify some needs that we can provide some significant improvement with during an initial intake assessment, and empowering staff to address such issues in real-time provides a novel opportunity to commence a trusting relationship and demonstrate to our clients an initial program effectiveness that they may not have experienced before.

In any given community we recommend the creation of an Immediate Access Fund for this purpose.  Staff is empowered to use this fund to provide any number of resources to patients that they may identify as an immediate unmet need. Expenses for which staff typically use the Immediate Access Fund include:

  • Cell phones – Staff will commonly provide clients without a phone with a phone, with the stipulation that as long as the client responds to text messages from the organization, we will pay for the subsequent month’s cell phone coverage.
  • Transportation – Most commonly, the account is used to obtain monthly bus passes for clients, but we will often pay for transportation to appointments and/or other events
  • Clothing – It is not uncommon for staff to bring items of clothes to clients during scheduled meetings, or even to temporarily step out to buy items for patients in crisis during an ED encounter and/or an intake assessment is such needs are identified.
  • Food – Similarly, staff may meet clients in an establishment and pay for a meal, and/or take them to a local food bank and assist with food collection
  • Medications – Occasionally staff may assist with coverage of medications temporarily
  • Housing – Less frequently, but in more critical situations, staff may use the IAF to assist with immediate housing needs

Use of funds in this fashion do not appear to be in violation of any Medicaid regulations, and in fact, several recent state Medicaid reimbursement strategies have begun to require targeted use of funds in a manner that can demonstrate improved client engagement in the manner demonstrated by these practices.

In our practice, staff are required to submit receipts at the end of every month with any expenses used by the Immediate Access Fund.  We regularly monitor spending in the fund in each community we serve; while annual usage may vary, it is common for a community of about 250,000 to have access to an annual fund of about $50,000 for these purposes.

Immediately upon client enrollment staff will conduct a thorough intake assessment with the new enrollee and contact community resources individuals are already engaged with – primary care providers, medical specialists, care coordinators and/or current treatment programs they may be involved with.  These activities provide a wealth of information that staff then summarized into an individualized patient care plan.

Many patients enrolled in high utilization programs will already have care plans of some form.  These are an extremely valuable resource, and staff should review these thoroughly.  That said, in many cases existing care plans can be quite detailed – often several pages long.  The value of care plans is primarily for the end-users, most often providers treating the individual – an emergency physician in a crisis event, a hospitalist or social worker during hospitalization, or an outpatient provider at a scheduled visit.  Practitioners treating patients in these environments have limited time to sort through large amounts of data.  Detailed care plans are often ignored in these circumstances; there is tremendous value in being able to provide the most pertinent of details in a short, succinct fashion, particularly if the information is outlined/highlighted in a method that stands out to them and makes pertinent information readily available at a glance.

We strongly recommend care plans be succinct – ideally nor more than a page in length. Community end-users will find plans to be of most value when they have accurate information that is reliable, “up-to-date”, and actionable.  Information should be separated into short segments such as:

  • Demographics (including reliable contact information)
  • Existing providers
  • Medical history, current medications and allergies
  • Psychosocial history, including substance use/abuse
  • Potential violence notices
  • Pending appointments
  • Actionable provider recommendations for crisis events

Care plans are of most value when updated frequently.  “Care Plan Fatigue” is a detrimental phenomenon experienced in several communities that have implemented mandates for care plan implementation without close regard to the quality of the product being produced.  When providers encounter care plans which are not updated or are merely a templated format common to all patients irrespective of their unique issues, they quickly consider this wasted time and will be unlikely to continue engaging in care plan review.

Care plans should be updated:

  • After each emergency department visits and/or hospitalization, and out-patient visit
  • After each out-patient (primary care or specialist) visit
  • With any pertinent medical or psycho-social patient change
  • When any new actionable item is recommended by a patient’s provider and/or coordinator

When updated in this fashion, and made readily available to pertinent community resources, customized care plans are an indispensable patient’s treatment tool.

Critical to the success of any community-wide high utilization program is the ability to share pertinent information amongst community members.  This is particularly challenging within the healthcare industry, where health systems utilize a wide number of information platforms and information is rarely shared across platforms.  And added to this we must consider the sensitive nature of the psychosocial issues experienced by high utilization patients, often encompassing issues such as behavioral health and substance use, which carry their own set of regulatory compliance guidelines around information sharing.  Most community care systems – hospitals, jails, law enforcement agencies, out-patient medical providers, mental health institutions, substance treatment programs, court systems, and housing authorities (to name just a few) – have transitioned to electronic record-keeping, but in most cases information sharing is very limited within systems of care (say, between hospital, or between law enforcement agencies), and extremely rare across systems.

Being able to share pertinent information amongst all members of a care community is critical; if we can’t share information, we might all be working towards a common goal, but we are essentially speaking different languages, with a very limited understanding of what each other is doing.  This invariably leads to poor organization, duplication (often multiplication) of efforts, and ultimately wasted community time and resources.  Multiple agencies may be doing great work, but often in a vacuum, with the patient lost amongst an array of poorly coordinated efforts.

To help facilitate greater success, CBC Solutions recommends Collective Medical to make this critical information sharing possible. The Collective Platform seamlessly connects each member of a patient’s care team together for effective collaboration on even the most complex patients. Their platform empowers physicians, nurses, and other care providers to improve the quality and efficiency of patient care through actionable real-time patient notifications. Their nationwide network of engaged care team members offers transparency for providers through patient histories and collaborative care plans—identifying vulnerable patients in real-time and helping care teams address their needs at the point-of-care.

Fortunately, within the last decade, significant progress has occurred in implementing systems of “common language” across communities.  Many health systems now have electronic record systems that can be shared amongst all members of that system, and regional government programs have provided much-improved data sharing in certain target communities. But arguably the greatest progress has occurred via the adoption of platforms that allow for HIPPA secure data sharing across institutions, care systems, and in some cases across the county and state lines.   It is very common for an emergency physician to have access to care plans, recent visit histories, and information on prescriptions that may have been filled even earlier that day when certain platforms are in use within or across states.  In the state of Washington (where I reside and practice) we experienced a 15% decrease in frequent utilizer emergency department visits just by the implementation of a state-mandated common data-sharing platform in 2011.

We feel the criteria for a valuable community-wide IT platform include:

  • Ability to interact with all community electronic medical records
  • Ability to engage with state Prescription Monitoring Programs databases
  • Serve as a portal for prompt sharing of customized patient care plans
  • Allows for data sharing across state lines
  • Can be shared with multiple community partners in HIPPA compliant fashion
  • Immediate access by appropriate end-user providers – Emergency department personnel, admission hospital personnel (hospitalists, social workers and hospital-based care coordinators), and out-patient providers (primary care providers and patient care specialists)

A high functioning common community IT platform is a critical component in the success of any community-based high utilization program. CBC Solutions is proud to partner with Collective Medical to facilitate a successful outcome for communities.

You can review other Community High Utilization Program Best Practices, and find additional information HERE.

High utilization patients are typically identified as having high emergency department visits, frequent hospital admissions, or high medical cost utilization. But in almost every case these patients are high utilizers of a vast number of community resources. True patient and community improvement occur only when we can identify these resources and engage them all in dialogue towards client improvement. Historically, failure to achieve this within a community has resulted in duplication (often multiplication) of care efforts, ineffective cost allocations, and most egregiously less-than-ideal identification and addressing of client needs.

Actually, while identifying the various resources involved in an individual’s care is a good first step in community resource engagement, true effective resource management requires much more –  we have to recognize how the client is affecting each resource, where opportunities for improvement may exist, understand and promote common efforts towards client (and resource) needs, and communicate our common efforts effectively across the community of care.

Some community resources that must be engaged in early dialogue are fairly intuitive:

  • Hospitals (particularly emergency department personnel, hospitalists, and social workers)
  • Community Care Coordination services
  • Primary Care Offices (and Specialty Care Offices)
  • Psychiatric Care Facilities and Behavioral Health Centers
  • Substance Use Rehabilitation Centers

Other resources may not be engaged as frequently, but are just as vital for success:

  • Local housing and transportation authorities
  • EMS and Law Enforcement Agencies
  • Food and clothing services
  • Jails and Therapeutic Court Agencies
  • Protective Service Agencies

High utilization program staff are in a unique position to coordinate efforts across the community of care, but to do so effectively they must spend time with each community resource, understanding how and where client engagement issues occur.  Staff must become familiar with each resource’s communication techniques, and help facilitate client communication amongst community resources in a compliant fashion.

One very effective tool that can promote community resource inter-communication is the creation of a monthly high-utilization client forum. This provides an opportunity for various community resources to meet together on a frequent basis to discuss common client issues together. Program staff can host these meetings, making sure to invite each of the resources invested in a client’s care in attendance. Given the sensitive nature of the discussions, and in accordance with CFR-42 (Code of Federal Regulations #42), clients must give consent for their information to be shared in such a forum.  We recommend a written consent form identifying all individuals that will be involved in said discussions, and signed by the client before any such dialogues occur. You will find that these multi-disciplinary forums will quickly become a staple in community program development.

To learn more, contact us today!

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A small but significant portion of individuals in communities around the country struggle with psychosocial issues – homelessness, mental health challenges, substance use and addiction, and/or challenging medical conditions. Their needs often go unmet, leading to high resource utilization or crisis events. They are typically identified by meeting one or more of the following criteria:
<ul>
<li>Frequency of ED visits or hospitalizations in a given period of time</li>
<li>Top % of cost of members within a community (often the top 1-2% or a payer cohort)</li>
<li>Identified by a community resource as a high utilizer of their services</li>
</ul>
Frequently these individuals already have some form of assigned care coordination. But the needs of these individuals are unique; standard telephonic or off-site care coordination practices are not substantial enough. This small cohort of individuals is best served by staff available within the community, familiar with their unique needs, and with intimate knowledge of community resources. We recommend each community have a dedicated regional program coordinator, – a licensed RN or MSW with care coordination experience – working with a team of community workers, as well as targeted administrative support.

Staff in these programs spend the majority of the time – in many cases over 90% of their time – in the field! The initial period of program enrollment tends to be the most time consuming; some studies have shown that up to 20% of staff’s time with clients occurs during the first month of program enrollment. Within days of enrollment team members should meet with new clients to conduct an intake assessment. The initial intake should be done in a calm environment, if possible in the client’s residence; it is an opportunity for to identify perceived risks, goals, history (medical, behavioral and social), perceived hurdles, and pertinent demographic information. This is also an opportunity for staff to begin dialogue with clients on initial service opportunities available to address their needs.

Early “wins” are crucial, and we highly encourage staff to address issues as they are identified wherever possible.
Within the first month of program enrollment, staff should create an individualized care plan for each client (care plan creation is the focus of an upcoming article), and promote its availability within the community. Following, or in some cases simultaneously with, care plan creation, staff work with clients to prioritize and begin to address identified needs – this often involves assisting with accesses to rehab or treatment programs or perhaps aiding with obtaining housing or transportation. Early in program enrollment staff often escort individuals to their office visits.

Throughout enrollment, staff will typically engage clients (and update their care plans accordingly):

• During or immediately after each emergency department visit
• During every medical or mental health admission
• After most primary care and/or specialist office visits
• Upon client requests for any variety of requests

This level of intense client resource management does make a significant difference – within months of enrollment community resource are used more effectively, and crisis events decrease. Staff live within communities being served is THE main differentiator of a successful high utilization program.
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