High utilization patients are typically identified as having high emergency department visits, frequent hospital admissions, or high medical cost utilization. But in almost every case these patients are high utilizers of a vast number of community resources. True patient and community improvement occurs only when we can identify these resources and engage them all in dialogue towards client improvement. Historically, failure to achieve this within a community has resulted in duplication (often multiplication) of care efforts, ineffective cost allocations, and most egregiously less-than-ideal identification and addressing of client needs.
Actually, while identifying the various resources involved in an individual’s care is a good first step in community resource engagement, true effective resource management requires much more – we have to recognize how the client is affecting each resource, where opportunities for improvement may exist, understand and promote common efforts towards client (and resource) needs, and communicate our common efforts effectively across the community of care.
Some community resources that must be engaged in early dialogue are fairly intuitive:
- Hospitals (particularly emergency department personnel, hospitalists and social workers)
- Community Care Coordination services
- Primary Care Offices (and Specialty Care Offices)
- Psychiatric Care Facilities and Behavioral Health Centers
- Substance Use Rehabilitation Centers
Other resources may not be engaged as frequently, but are just as vital for success:
- Local housing and transportation authorities
- EMS and Law Enforcement Agencies
- Food and clothing services
- Jails and Therapeutic Court Agencies
- Protective Service Agencies
High utilization program staff are in a unique position to coordinate efforts across the community of care, but to do so effectively they must spend time with each community resource, understanding how and where client engagement issues occur. Staff must become familiar with each resource’s communication techniques, and help facilitate client communication amongst community resources in a compliant fashion.
One very effective tool that can promote community resource inter-communication is the creation of a monthly high-utilization client forum. This provides an opportunity for various community resources to meet together on a frequent basis to discuss common client issues together. Program staff can host these meetings, making sure to invite each of the resources invested in a client’s care in attendance. Given the sensitive nature of the discussions, and in accordance with CFR-42 (Code of Federal Regulations #42), clients must give consent for their information to be shared in such a forum. We recommend a written consent form identifying all individuals that will be involved in said discussions, and signed by the client before any such dialogues occur. You will find that these multi-disciplinary forums will quickly become a staple in community program development.