For The Uninsured In Memphis, A Stronger Safety Net

Abstract

A new model moves high-need patients out of the emergency department and into a rich network of social supports.

Insights Results

Overview of article/program

This article provides an overview of the development, components, successes and impacts of ONE Health in Memphis, TN

Drawing upon strategies that have worked for several other health systems, Regional One has built a model of care, ONE Health, By working with a network of about 250 community groups across the region, the hospital has an ambitious plan to help as many medically complex uninsured patients as it can through the ONE Health program. The hope is that its efforts will mean healthier people and fewer hospital visits

ONE Health began with building a hot-spotting program that was tailored to Regional One. Next they constructed a care coordination strategy that involved engaging and partnering with Memphis’s nonprofits. ONE Health Connect, an online tool helping people find a free or reduced-cost social services organization in the Memphis area near them, was also established

ONE Health team’s work is finding patients through hotspotting, enrolling them, getting them care coordination, connecting them to social services, and then moving them to a place where they can care for themselves. To move patients toward their own health management, the team uses authentic healing relationships, an evidence-based strategy that involves a health provider developing a secure and genuine connection with a patient

ONE Health uses an assessment form to help patients identify their needs. The focus assessment form focuses on housing, transportation, legal issues, talking to someone about mental health challenges, improving family relationships and relationships with healthcare providers, accessing medical equipment or disease management education, advocacy and activities, talking to someone about drug or alcohol abuse and accessing food

Based on the assessment form, the ONE Health team builds a care coordination and management strategy that includes connecting the patient to primary care provider, then through its community partners to the social services. The plan is documented in an electronic health record (EHR) where it can be accessed or updated by anyone on the care team

The criteria for graduating patients are related to how far the person has moved toward self sufficiency and having socioeconomic needs met

Results

ONE Health has reduced uninsured ED visits by 68.8%, inpatient admissions by 75.4%, and lengths-of-stay by 78.6%—averting $7.49 million in medical costs over a 15 month period. Because of the success, Regional One is looking to expand the program to the hospital’s Medicare and Medicaid patients
As of June 30, 2019, 65 patients were considered graduated from ONE Health. The criteria for graduating patients are related to how far the person has moved toward self-sufficiency and having socioeconomic needs met
Efforts to scale ONE Health up are underway. Expansion includes hiring another nurse and social worker team, and hopefully, one day expanding the program to Medicaid and Medicare beneficiaries

Key takeaways/implications

The model has had success because it combines data analysis and community connections and is led by a team of nurse leaders experienced in complex care. Many of the community connectors provide social services that address social determinants of health (e.g., housing, level of education, access to transportation and employment)
The process of moving people towards independence is time consuming and should be considered in program development and evaluation
Another important component of success is having a nurse leader and a strong nurse community. ONE Health has a dedicated space with a waiting room, a visit from SNAP to the office to help patients with the program’s benefits, and a storage space converted into a once-a-week food pantry