Timmy Williams was dying when Dayna Gurley found him. He was in his home with untreated HIV. He was unable to take care of his young son. Dayna arranged a home aide for Timmy, had his apartment cleaned and helped him get his lights turned back on. She engaged resources to help him manage his HIV.
Dayna is a medical social worker tasked with figuring out why patient’s like Timmy use more health care services than almost anyone in Houston. She works at Houston’s Patient Care Intervention Center. In the two years it has been running, costs for those in the program have gone down 83% and hospital visits were reduced by 70%.
High Cost High Need patients are well represented in the 5% of American’s that consume 50% of all of the healthcare spending. A Health Affairs study published this week describes the success of Partners Accountable Care Organizations (ACO) Care Management program. They targeted Medicare patients with elevated but modifiable risks for future spending. The Partner’s ACO was able to reduce ED vists by 6%, hospitalizations by 8% and Medicare spending by 6%.
There are several High Need High Cost patient programs that have proven to be successful:
Hennepin Health’s outreach program helps clients find a job or an apartment. The project has shown it can improve patients’ health while saving money and greatly reduce the number of times they turn up at the ER in crisis.
A strategy focused on team-based care and listening to “super-users” helped a Florida health system cut hospitalizations of such patients by a quarter while also driving down uninsured admissions.
Intensive Outpatient Care Program (IOCP) embeds care coordinators in medical practices. Care coordinators work with high-needs patients in medical practice where patients, emergency room visits declined 59% and admissions declined 29%.
Project ECHO’s Complex Care Initiative builds capacity to help “superutilizers” in underserved communities. The number of hospitalizations among participants fell by 27% and emergency department visits dropped by 32%.
The Chronic Care Plus initiative tracks superusers through the healthcare system and works to find lasting solutions for their ailments and health problems. Their ‘intensive care coordination’ saved $14M in superuser costs.
Intensive Outpatient Care Program (IOCP) in commercial populations show a reduction in costs among the medically complex by up to 20 percent.
Initiative to reduce avoidable hospitalizations among nursing facility residents reduced per resident average of $60–$2,248 for all-cause hospitalizations and by $98–$577 for potentially avoidable hospitalizations.
See interventions for more on what works.
See determinants for insight into what impacts health outcomes.