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HEALTHY LIVES: Community-Based Care Coordination for Complex Patients
Photo: David Binder
H e n r y W h i t e , M D
H a n n a h S c o t t , P M H N P -B C
SOCIAL DETERMINANTS
OF HEALTH MEDICAL
BEHAVIORAL HEALTH
The CHALLENGE
*
The patient population lies at the intersection of those with high medical needs, complicated behavioral health needs, and multiple needs related to the social determinants of health.
SOCIAL DETERMINANTS
OF HEALTH MEDICAL
BEHAVIORAL HEALTH
The SYSTEM
*
Most care for complex patients is delivered in segregated systems. Providers in each system work in isolated settings without inter-disciplinary communication or integrated care planning.
Healthy Lives
Community Mental Health Center Based
Community Based w/Hospital Integration
Community Health Center Integration 2010
2012
2014
2017
ACO Co-location
(TCCI)
• Started in response to patient needs • Provides integrated, community based care • Tested in varying healthcare settings
The TEAM • Managed by a Nurse Care Manager or LICSW • Consists of Bachelor’s Level Community Health Workers • Share proficiency in medical, mental health, and social
service expertise
The APPROACH • Begin with patients in their home environments • Goal: build a comprehensive understanding of the patient’s
environment including family, friends, agencies, and providers
patient
@ HOME
FAMILY
HEALTHCARE
COMMUNITY
The INTERVENTION
• Form a team around the patient for long-term support
• Address all domains of health
• Connect providers and supports
• Create an integrated, shared understanding of the patient for all team members
patient patient
Utilization
Access Basic Needs
Activation
Functioning
The EXPERIENCE
patient
“SUSAN”
• Low fixed income • In danger of eviction • Isolated/No social supports
• Diabetes • Obesity • Congestive Heart Failure • Heavy Smoker
• Bipolar 1 Disorder • Distrustful • Poor executive functioning
SOCIAL DETERMINANTS
OF HEALTH
MEDICAL
BEHAVIORAL HEALTH
The EXPERIENCE
patient
SOCIAL DETERMINANTS
OF HEALTH
MEDICAL
BEHAVIORAL HEALTH
INTERVENTIONS
• Consolidate debts • Collaborate with housing • Connect to service providers
• Meal Planning & Delivery • Daily Weights • Appointment Attendance • Smoking Cessation
• Integration of Care Team • Focus on Relationship Building • Concrete Assistance w/Tasks
Inpatient Utilization (per patient/year)
Health Outcomes
68% of patients showed improvement
in relevant outcome selected at enrollment
e.g A1c, BP, BMI, pain
Homelessness
18% of patients reported homelessness or housing instability at engagement
2% reported after 9
months of enrollment
*Data annualized and based on 12 months pre-enrollment and
annualization of 9 months post-enrollment for all measures; n=41
2.5 1.6
before after
3.8 2.5
before after
9 Month Interim Outcomes ED Utilization (per patient/year)
30-Day Readmissions (per patient/year)
0.37
before after
0.88
The CONTEXT A hierarchy of care coordination/care management services has been developed by healthcare systems.
“USUAL CARE”
+ RESOURCE SPECIALIST SUPPORT
+ CARE MANAGEMENT
* 1:1000
1:300
1:25
HEALTHY LIVES
NEXT STEPS
Community Mental Health Center Based
Community Based w/Hospital Integration
Community Health Center Integration 2010
2012
2014
2017
ACO Co-location
(TCCI) ACO Consultation
(SHIFT-Care)
2018
SOCIAL DETERMINANTS
OF HEALTH MEDICAL
BEHAVIORAL HEALTH
In CONCLUSION By creating a shared, integrated understanding of the patient and assembling a long-term care team for a patient’s comprehensive needs, health care costs are significantly decreased and patient health outcomes are improved.
patient
POLICY IMPLICATIONS • Recognition of the impact of complex, multidimensional
systems on health
• Targeting high-cost, high-need patients with flexible, intensive, community-based interventions
• Provide integrated training opportunities for healthcare professionals
• Necessity of integrated electronic health records and information exchange between providers
c o n t a c t u s H e n r y W h i t e , M D
C l i n i c a l D i r e c t o r
h e n r y w h i t e @ b r o o k l i n e c e n t e r . o r g
H a n n a h S c o t t , P M H N P - B C
D i r e c t o r o f C a r e S t r a t e g y & N e w B u s i n e s s D e v e l o p m e n t
h a n n a h s c o t t @ b r o o k l i n e c e n t e r . o r g