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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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We have an opportunity within healthcare to make an impact – a huge impact.

Healthcare costs now consume 18% of the GDP, $3.5 trillion in 2017 (1).  But a very small cohort of individuals account for an inordinate amount of this expenditure – the Department of Health and Human Services informs us that 1% of individuals account for 21% of all healthcare costs (2).  While a portion of these patients have few options other than expensive medical treatments, a significant portion of this cohort struggle with psychosocial issues that are poorly addressed in many communities, resulting in significant unnecessary expenses.  According to 2016 CDC data, almost a fifth of annual emergency department visits, a total of over 24 million visits at a cost of $11.2 billion, are attributed to frequent utilizers – those with 5 or more visits within the prior 12 months.  Amongst frequent ED utilizers nationwide:

  • 30% are homeless
  • 40% have a primary mental health disorder
  • 50% have a primary substance abuse disorder

When these individuals struggle in accessing the service they need and crisis ensues, they come to the one place they know will always be open – their local ED. We are blessed with wonderful emergency medical services throughout our nation, but our ED’s are not designed nor equipped to address these issues.  At best EDs can address the medical crisis that may be immediately at hand, but typically the patient is discharged back into the same environment, and when the next crisis invariably occurs, the cycle repeats itself.

Over the last decade, frequent utilizer programs in New Jersey (3), North Carolina (4), Minnesota (5), Maryland (6), Washington (7), Oregon (8) and Alaska (9) have all demonstrated dramatic success – reductions in hospital utilization varying from 40-60% within a year of program implementation, with dramatic net cost savings, demonstrated in each of these programs, and a cadre of metrics indicating improved quality of care.  Most of these programs are designed around models of care that can be reproducible within almost any community across the country. While each of these programs have components that are customized to communities, there are traits that are shared across all of the programs and other traits that are common amongst many of them, and repeatedly found to bring significant value when implemented.

This is the first of a short series of articles.  We hope in this introductory article we have heightened your awareness of this very important issue our nation is facing.  Over the next few weeks we will be sharing  a series of articles, each of which will highlight each of the following “best practices” shared by successful high utilization programs implemented across our country to date:

  • Staff live in communities being served
  • Community resource engagement
  • Customized patient care plans
  • Common community IT system
  • Immediate access fund
  • At-risk payment models

High utilization patients have suffered for decades as our medical communities have struggled to address their needs.  We now know that we can do better.   We can make a difference – a significant difference.  It is time to make an impact….

References

  1. National Health Expenditure Data, 2018 – CMS.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata
  2. Department of Health and Human Services Statistical Brief #421: Differentials in the Concentration in the Level of Health expenditures across Populations Subgroups in the U.S., 2010. file:///Users/papa/Dropbox/CBCS/Articles/Costs%20of%20Utilizer%20Care/AHRQ%20-%20Cost%20of%20Top%201%25,%202010%20-%20STATISTICAL%20BRIEF%20%23421_%20Differentials%20in%20the%20Concentration%20in%20the%20Level%20of%20Health%20Expenditures%20across%20Population%20Subgroups%20in%20the%20U.S.,%202010.htm
  3. Camden Coalition Hot Spotting Program – https://hotspotting.camdenhealth.org/
  4. Community Care of North Carolina – https://www.communitycarenc.org/
  5. Hennepin Health – https://www.commonwealthfund.org/publications/case-study/2016/oct/hennepin-health-care-delivery-paradigm-new-medicaid-beneficiaries
  6. Health Care Access Maryland –  http://www.healthcareaccessmaryland.org/media-listing/access-health-program-achieves-demonstrable-reductions-in-avoidable-hospital-utilization-by-addressing-social-determinants-of-health-and-linking-residents-with-community-resources/
  7. Consistent Care Program – https://consistentcare.org/
  8. The Health Commons Project – https://oregon.providence.org/our-services/c/center-for-outcomes-research-and-education-core/population-health-dashboards/the-health-commons-project/
  9. Mat-Su Health Foundation HUMS Program – http://www.healthymatsu.org/What-We-Do/Strategies/minds-1.html

CBCS’s base model of care involves an annual enrollment fee per member, with dramatically reduced annual renewal fees.  These fees are based on a guaranteed costs reduction of 30% within the first year of program implementation.  This service model is not intended to replace existing models of service within the community and/or organization; indeed, our organizational history shows existing resources invariably welcome the synergism our services provide and become our greatest proponents within short order of program implementation.

CBCS recognizes that certain communities and/or organizations prefer to retain services such as ours within their current systems of care, and for such organizations, we have developed partnership and consultation models of care.

CBCS welcomes an opportunity to discuss either of the above models of contracting in more detail.  Please submit such request via our “contact us” portal.