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