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:
<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>
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.