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Webinar: Homelessness and Emergency Department Care
Wednesday, March 16th, 2022 | 1:00 PM CT

People experiencing homelessness are often managing significant complex health issues but are unable to access needed primary care or must prioritize immediate survival over health management. The result is that health conditions are often untreated until it’s an emergency. Emergency Departments (EDs), then, are well accustomed to serving people experiencing homelessness. But with competing priorities and a dearth of education on homelessness and harm reduction, ED providers can overlook opportunities to coordinate services for people without homes. This lack of coordination often results in the same individuals continuing to access health care through the ED, resulting in frustration for providers and the person seeking health care. It doesn’t have to be this way.


Join CBCS Founder and CEO, Dr. Enrique Enguidanos on March 16th, where he will discuss what Emergency Department staff need to know about the context and stigmatization of homelessness, the role of trauma in serving this population, and the services health centers offer in support of EDs.

Hosted by National Health Care for the Homeless Council. Register here.


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Solving for Patient Engagement in Behavioral Health Populations

Behavioral health conditions significantly impact costs of care—with studies linking behavioral health diagnoses with a 3.5x increase in overall care costs and up to a 103% increase in high-cost utilization.

While innovative health plans across the country are working to address these costs through programs tailored to support individuals with behavioral health conditions, patient engagement in these programs remains low. Without proper engagement, care costs for patients increase an additional 8-21%, and both behavioral and physical health outcomes decrease.

CBCS supports health plans across communities in achieving measurable cost savings for behavioral health patients by overcoming barriers to engagement and enlisting community resources to create unified, holistic solutions for improving behavioral health outcomes.

Addressing behavioral barriers to patient engagement

Patients with serious mental illnesses and behavioral health diagnoses, such as substance use disorder (SUD), traditionally have a high treatment dropout rate. In low-income communities this is even more prevalent, with studies showing that 45-60% of adult patients and 80% of adolescents with a behavioral health condition drop out of treatment before the minimal standard for treatment has been met.

The traditional healthcare system requires behavioral health patients to come into a clinic or login to a portal to receive appropriate care, failing to account for the unique socioeconomic and behavioral challenges these patients face. These challenges act as barriers to care, showcasing the need for health systems that both anticipate and address needs such as lack of transportation, means, or motivation in order to ultimately improve program engagement.

CBCS breaks down traditional engagement barriers by meeting patients where they are. 40% of CBCS patients have a mental disorder, 50% have significant substance use disorder, and many face additional social determinants of health which can make it difficult for health plans to reach them through traditional channels, such as phone or mail. As such, CBCS specialist teams instead leverage existing state and private Health Information Exchanges to be ready, 24/7, to meet patients in their moments of crisis and provide both the temporal and clinical support needed to move forward.

By willingly meeting patients where they are—whether at the emergency department, the home, or the McDonalds up the street—CBCS provides a convenient and trustworthy entry point for patients in entering the mental health care system, intervening and triaging moments of crisis to minimize acuity and improve patient outcomes.

Engaging community resources for improved outcomes

When we work within siloed healthcare systems, even the best behavioral health programs fall short by failing to engage with all stakeholders in a patient’s care cohort. Taking conversations outside clinical doors to include the community resources that patients are touching daily is key to holistic and long-term successful care management.

CBCS is a proven facilitator in bringing together community resources to create the care cohorts necessary for total patient care. For members with a behavioral health diagnoses, this could mean bringing together the local fire department, law enforcement, housing authorities, food banks, and shelters to discuss with the patient’s primary care physician, case manager, and therapist what outstanding needs the patient has—and how to troubleshoot a solution as quickly and effectively as possible.

As interdisciplinary teams across the medical and community neighborhood work together to support each other, patients feel cared for and collaboration increases as the unified effort allows all stakeholders to benefit from providing simpler, and more effective care.

Improving cost and clinical outcomes with CBCS

CBCS has proven the cost efficacy of its patient engagement methods—demonstrating an average 5:1 cost reduction rate within the first year of program implementation, and a 10:1 ROI upon subsequent years. And for organizations leveraging CMS or Biden funding grants, that return is even higher.

How? Improving clinical outcomes.

CBCS programs average a 45% reduction to ED visits and hospitalizations and a 41% reduction to no-show rates. In our SUD populations, opioid prescription utilization decreases an average of 30%.

These quick returns support healthy bottom lines for health plans by delivering high-impact results—at minimal upfront cost. All while ensuring high quality and affordability of care, at scale.

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CEO Dr. Enrique Enguidanos to present at the 2021 American Public Health Association Conference


The American Public Health Association’s 2021 Annual Meeting and Expo will take place Oct. 24-27. The 2021 theme is “Creating the Healthiest Nation: Strengthening Social Connectedness.”

On October 27th, Dr. Enguidanos will be co-presenting COVID Response from Multiple Perspectives with the Cuban Society of Public Health, offering contrasting perspectives on the challenges faced in Cuba and the United States related to the management of COVID-19. Dr. Enguidanos will be presenting “An Overview of the U.S. COVID Experience.”

The purpose of the quarterly dialogues is to examine key public health issues in both Cuba and the U.S.  Through the leadership of their respective national associations (Cuban Society of Public Health and the American Public Health Association), the intent is to carry these conversations to the state/local level and engage with stakeholders who are critical to carrying out this work.

Co-organizers: Cuban Society of Public Health (SOCUSAP), Pennsylvania Public Health Association (PPHA), Public Health Management Corporation (PHMC) and American Public Health Association (APHA)


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Webinar: Enhancing care coordination across the continuum: A guidebook to reducing readmissions


Tuesday, September 21st, 2021 | 12:00 PM – 1:00 PM CT

Readmissions are a significant driver of healthcare costs and inefficiencies, accounting for $26 billion per year across the U.S. Join our CEO Enrique Enguidanos as he sits down with fellow physician thought leaders to discuss challenges and strategies to reduce ED readmissions. Hosted by Becker’s Healthcare. Register here!

Becker’s Healthcare is the go-to source for healthcare decision-makers and one of the fastest-growing media platforms in the industry. Through print, digital and live event platforms, Becker’s Healthcare equips healthcare leaders with the information and forums they need to learn, exchange ideas, and further conversations about the most critical issues in American healthcare

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CBCS is excited to be featured on Population Health Learning Network


Enrique Enguidanos, MD, FACEP, MBA, CEO and founder of Community Based Coordination Solutions discusses how CBCS is rethinking the complex engagement model

It was the tenth time Mary had presented to the emergency department (ED) suicidal and intoxicated after trying to subvert her depression with alcohol. This time, a caring bystander had called 911 as they saw her laying on the sidewalk mumbling and the ambulance had brought her to the one place that was open after hours—the ED.

Mary’s story is not unique; research shows that roughly one in four Americans suffer from a diagnosable mental illness. When complicated by other psychosocial conditions such as substance abuse, homelessness, or chronic medical conditions, our country’s medical care system can be disheartening to navigate.  All too often, this leads to poor preventative care and eventually higher incidences of crisis events such as Mary’s. One term used to describe patients at such risk is “complex care patients.” Our current system of care for complex care patients isn’t working; a new approach is needed—one that accounts for these conditions and better leverages in-person connection to address them.

Read the full article here.

Read More | Posted In: News

Caring As Communities Podcast Episode 15: Addressing Stigmas in Healthcare

Stigmas promote feelings of isolation, unworthiness, and unwelcomeness, leading to discomfort and distrust. Yet they are a common reality in healthcare—especially for patients with social determinants of health, chronic conditions, or addictions. Drs. Stephen Anderson, FACEP, and Donald Stader, FACEP, join Jeneen Skinner of the Camden Coalition to discuss how we can reduce these stigmas in our workplaces.

This podcast is available on AppleSpotifyGoogle Podcasts, and our hosting Buzzsprout platform.



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Caring As Communities Podcast Episode 14: Engaging Patients with Complex Care Needs

It’s the Caring As Communities Podcast’s one-year anniversary, and Dr. Enrique Enguidanos steps away from the role of host and instead shares his own insights after over a decade of dedicated work in the complex care space. Tune in as he shares key strategies for engaging patients with complex care needs by working in tandem with community resources.

This podcast is available on AppleSpotifyGoogle Podcasts, and our hosting Buzzsprout platform.




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Improving outcomes through patient engagement
Keeping healthcare personal, scalable, and affordable with the CBCS direct patient engagement program

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.

Read More | Posted In: Case Study, model of care, News

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.

This episode is available on Apple PodcastsSpotify, Google Podcasts & Buzzsprout, which provides a full transcript of this podcast as well.

Read More | Posted In: model of care, News, Podcasts

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.



Read More | Posted In: Catalyst Program, model of care, News