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.
Our Direct Patient Engagement Training Program consists of 6 focused segments. Each segment addresses a key element in assisting and improving the ability to reach traditionally “hard-to-reach” and complex patients.
Results at a Glance
Our clients enjoy the following results after working with us on Direct Patient Engagement:
40% Reduction in ED Visits and Admissions
50% Reduction in Opioid Prescriptions
$40,000 Reduction in Costs per Enrolled Member
Initial Engagement of Hard-to-Reach Complex Patients
Patient engagement is critical to any care coordination program – without patient engagement, all other efforts are of limited value. Segment 1 provides an in-depth focus on the basics of CBCS’s complex care patient engagement efforts. We introduce our standard approach to patient engagement, as well as offer tips that we have learned over the years that improve engagement of hard-to-reach complex care patients. We review our 10+ page Intake Assessment form, the validated assessment tools we incorporate into the IA, and insight into how to most effectively use the IA. We also review our organization’s policies, guidelines and protocols, and offer suggestions on how to organization weekly and daily program meetings.
Maintaining Patient Engagement
Segment 2 provides a deeper dive into the patient engagement efforts, building on the information introduced the previous month. We discuss how to effectively engage with members during crisis moments, including emergency department visits and hospital admissions, and how staff may effectively assist enrolled members during provider appointments. We provide deeper insight into our efforts around program communication and personal safety, as well as recommendations on documentation and report filing. We also discuss the importance of an Immediate Access Fund for program staff.
Maximizing the Value of Care Plans
Care Plans, when effective, can be of tremendous value to community end-users such as emergency department providers, primary care physicians, and other community resources.
During this segment, we review how to create an effective care plan with member participation and with an “end-user” focus. We offer insight into how to best “train” community resources into participating and promoting these care plans, and how to keep them effectively updated. We also discuss the value of community tools such as Health Information Exchanges and Community Information Exchanges, and how these might help promote Care Plan utilization.
Engaging Community Resources
Complex patients touch multiple community resources; in most cases, these resources have also been trying to improve their relations with these same members. Hence, there is usually an inherent incentive for these community resources to engage with us in finding a “better way”, and in avoiding duplication of efforts. A united approach to common patients invariably leads to more effective care, improved patient communication, and cost reductions for all involved.
In this segment, we offer insight into the lessons learned by CBCS in community resource engagement and leadership. We provide recommendations on how to begin dialogues around common goals and efforts, as well as how to maintain communication and joint efforts towards common community goals.
Patient Engagement and Healthcare Compliance
Healthcare compliance is coming under increasing scrutiny. As federal and state guidelines evolve, and tools such as electronic medical records and community exchange programs gain increasing use, it is imperative that organizations maintain strong compliance structures.
In this segment, we share our expertise on effective compliance within our complex care programs. We discuss HIPPA, EMTALA, and CFR-42 federal regulations, and their pertinence to the complex care coordination work we do. We review CBCS corporate compliance, discussing issues such as information security when using desktop computers, laptops and cell phones. We review steps for addressing unauthorized access/breaches to these devices and offer suggestions on texting/messaging compliance. We also discuss COVID considerations, the value of scripts for consistency within complex care communications, and offer insight into complaint management.
Transitions and Communications
When is the right time to consider program enrollment? And when might an enrolled member be ready to transition out of the program – either to a less intense program or perhaps back into our general membership pool? What metrics and/or criteria should we use to make these decisions, and how might we continue to monitor these decisions after they are made. Our final segment addresses each of these concerns. Medical and Mental Health admissions are particularly resource-intense and high-cost events; it is imperative we maximize their effectiveness and work diligently to avoid recurrences after discharge. This segment also focuses on how to maximize communications and transitions during hospital admissions, including how to best coordinate with hospital and community staff to maximize post-discharge courses of care. We also provide in this segment our expertise on creating program Balanced Scorecards, and how these can be effectively used to access and communicate on program performance within our organization and within our community at large.