Improving outcomes through patient engagement
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.
Why we need to rethink patient engagement
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.
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.
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: https://cbc-solutions.org/programs/
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!