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.
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.