At the Mat-Su Health Foundation in Wasilla, Alaska, external programs and partnerships were put in place and funded to help address social determinants, which were affecting patient care. Social determinants are non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.
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.
Because of this, 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.
Looking for a way to improve the effectiveness of community programs, the foundation partnered with CBCS to develop the High Utilizer Mat-Su (HUMS) program—a community-collaborative program utilizing CBCS to support high-risk populations by bringing together medical, behavioral and community resources to provide critical care and address social determinants.
Unlike previous programs, CBCS helped facilitate better cross-community collaboration, bringing together representatives from the local fire and EMS, emergency department, court system, jail, behavioral health crisis intervention team and more to create a working cohort for improving care.
In addition to setting up and facilitating these multidisciplinary cohorts, CBCS provided social workers that were available to meet high-utilizers when they arrived at the hospital, and get them set up for the next step—whether that’s following up to ensure understanding and adherence to prescribed care and medication plans, arranging transportation to follow-up appointments, or taking them to required follow-up MAT or primary care.
The HUMS program experienced significant, measurable success. Within two years of implementation, the program achieved:
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