Caring As Communities Podcast Episode 16: Addressing Social Determinants Through Technology Solutions (Part Two)
Health IT Solutions are becoming an increasingly integral component of organizational efforts to address social determinants of health.
Join us in part two of a special series with health IT leaders as we talk with Point Click Care Chief Medical Officer- Benjamin Zaniello, M.D., M.P.H.- about utilizing technology to connect individuals with the community resources they need.
A practicing Infectious Disease physician, Ben is also a technologist at heart, focused on healthcare innovation for Population Health and the transition to value-based care for all patients. His passion for care transformation comes from firsthand experience. Most recently Ben worked at Providence St. Joseph Health, as their Chief Medical Information Officer in Population Health.
Dr. Zaniello continues to practice medicine, focusing on Utah’s high-risk populations. His undergraduate work was at Stanford (in Architecture, German, and Computer Science) but he returned home to his native Kentucky for medical school at the University of Kentucky College of Medicine. He did his Internal Medicine residency at Weill Cornell Medical Center and Infectious Disease fellowship at the University of Washington where he also received his Master’s in Public Health.
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.
Caring as Communities Podcast: Addressing Social Determinants with Technology Part One
HealthTech is paving the way for addressing social determinants of health through a myriad of platforms, software, and more. Join us as we talk with health IT industry leader, Erine Gray—CEO and founder of Aunt Bertha—in this tech series and get insights for reducing gaps in care.
Erine Gray has been working on business and technology consulting projects for more than 15 years and is the Founder and CEO of Aunt Bertha. Aunt Bertha’s mission is to make human service program information more accessible to both people and programs.
Prior to founding Aunt Bertha, he directed more than 60 employees within a project responsible for administering the application process for the Texas Health and Human Services Commission. At the Commission, he delivered more than 40 software and operational improvement projects that saved more than $5 million dollars annually in operating expenses. Erine studied public policy at the LBJ School of Public Affairs at the University of Texas and has a BA in Economics from Indiana University. He’s a 2019 TED Senior Fellow.
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.
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!
Case Study from Collective Medical Highlights CBC Solutions’ Work
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.
*This Case Study was written by our exclusive IT partner, Collective Medical.
The Importance of Using a Real-Time Data Platform to Cut ED Visits & Care Costs
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.
Best Practice for a Community High Utilization Program – Immediate Access Fund
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.
Best Practice for a Community High Utilization Program – Customized Patient Care Plans
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.