For Super-Utilizers, Integrated Care Offers A New Path

Vaida B
Source: Health Affairs
Publication Year: 2017
Patient Need Addressed: Behavioral health, Care Coordination/Management, Food insecurity, Homelessness/housing, Patient satisfaction/engagement, Transportation
Population Focus: Complex care
Intervention Type: Partnership, Service redesign, Staff design and care management
Type of Literature: White

Many health systems continue to experiment with the best way to care for those patients who end up in the hospital most frequently.

Insights Results

Overview of article/programs

  • This article evaluates the different health systems and programs in place and in development that are intended to effectively address the care needs of super-utilizers
  • All of the models involve expanding a patient’s care from a single provider to an integrated health team that includes access to behavioral health and social services, such as food, housing and transportation
  • 2 systems’ work are viewed as aspirational by health leaders: the Camden National Center for Complex Health and Social Needs and Anchorage’s Southcentral Foundation’s Nuke System. Both systems have shown early promise in intensive outreach and long-term engagement in the local community leading to better health outcomes and a reduction in ED use and hospital admissions
  • The Camden Coalition brings together hospitals and community organizations to visit patients at home to try to keep them out of the hospital. The coalition also has data specialists who monitor EHR information to try and predict where health problems might arise in the future. The coalition is managing Medicaid ACO pilots in New Jersey as well
  • The Southcentral Foundation created one of the most integrated primary care practices in the country, also including dozens of community services into its care plans. Typical care teams within the foundation are composed of a doctor (focus on most complex cases), nurse (focus on routine care), case manager, medical assistant and pharmacists
  • State health leaders note that among the challenges they face, changing the culture of the current system is particularly difficult
  • Notably, CareOregon developed coordinated care organizations that received an innovation award from CMS to add a community outreach component because it was clear that this was a program really for complex patients. CareOregon built relationships with community groups and hired trained social workers, peer leaders with experience in addiction, health coaches and behavioral health specialists. This initiative has led to a drop in ED visits and increase in primary care use