How to coordinate care in a safety-net setting: 10 lessons

Eighty percent of factors that impact health are nonclinical. Most of what determines a individual's health is decided outside of the delivery system, yet a provider's ability to manage these outside activities can translate into significantly more control over patients' outcomes and the costs of care.

At the Becker's Hospital Review 9th Annual Meeting on April 13, Jeffrey Arnold, MD, CMO of Santa Clara Valley Hospitals and Health Systems, and Teddy Shah, senior client partner at Optum, presented their early findings from a pilot program designed to connect the social, behavioral and medical aspects of health for the system's most vulnerable patients, who are often homeless and have multiple chronic conditions.

Through enhanced care coordination, data sharing and engagement, the goal of the pilot was to more efficiently use resources and improve the health of patients. The five-year pilot, funded by CMS, is still underway. Here are 10 lessons the system has learned so far.

1. Think of "whole person care" — the coordination of health, behavioral health and social services — as outpatient intensive care. "Whole person care is one person supported by people acting as one team from organizations behaving as one system. It's easier said than done," Mr. Shah said. Managing inpatient intensive care within the four walls of a hospital is tough. Imagine the difficulty of providing outpatient intensive care for patients that are hard to contact and organizations that are not part of the hospital system. It requires a lot of time to get the concept right, Mr. Shah said.

2. Multichannel reach is the best way to engage patients. Engaging with the homeless population can be difficult, Mr. Shah said. Texting, calling and email are rarely sufficient forms of communication. Instead, face-to-face interaction yields the best results.

3. Providers may have to attempt many times before engaging patients. Dr. Arnold said it can take 15-20 instances of outreach to engage this patient population.

4. Electronic case management is not enough. While having a central office and backing the program up with data is really important, organizations need to provide case managers and clinicians with data they can actually act on. "You need people on the ground and a lot of warm handoffs," Dr. Arnold said.

5. Acute medical episodes motivate patients. This is a key opportunity for providers to engage with patients and start to establish or re-establish a care management relationship.

6. Complex patients may require multi-disciplinary case conferences on a weekly basis. Dr. Arnold recalled one elderly patient in particular with multiple chronic medical conditions, who was at risk of homelessness and had a major depressive disorder diagnosis. After 14 face-to-face meetings with peer navigators, multiple medical and behavioral health visits and case conferences, the patient was rediagnosed with mania associated with depression stemming from chronic medication side effects. The patient received the help and care he needed and now has a stable living situation and makes regular use of mental health services instead of the ED. This anecdote demonstrates the importance of regular meetings and check-ins to make sure a patient's care plan and diagnosis is on track.

7. High-acuity patients who utilize services at multiple health systems may need to "step down" and "step back up." The amount of care and engagement and patient requires may fluctuate.

8. Retrospective utilization scores are just the beginning. Systems need to revisit their patient populations often and determine whether they are addressing the right population and the right things, given that they are using retrospective data. Additionally, organizations should not underestimate the undertaking of pulling together data from multiple providers and agencies — and verifying its accuracy, storing it and securing it. However, this information will be critical to understanding the patients and the progress of the intervention.

9. Field staff are vital to patient engagement. "The best type of navigators are peer navigators," Dr. Arnold said. Santa Clara Valley Health tapped past patients and other community members to help current patients navigate the system and serve as point people who truly empathize with their situation.

10. More housing options, both temporary and permanent, are likely necessary. Providers will often need to stabilize a patient's housing situation to make any progress on their care plan. "If you don't understand the patient's needs, you can't address their key problems … You can give [a diabetic patient] meds and support systems, but if they don't have a house over their head and food, they aren't going to focus on that and you are going to lose a lot of money," Mr. Shah said.


More articles on patient engagement:

5 areas where greater patient engagement is a game-changer
Survey: 95% of patients say personalized onboarding pre-visit would be helpful
The new paradigm of patient relationship management

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