Tailoring Care and Saving Costs

Added to his uncontrolled diabetes and hypertension, 44-year-old Ray (not his real name) suffered from depression. He was a frequent visitor to the emergency room. His life conditions, or what are called the social determinants of health, like housing, income and transportation, prevented him from taking control of his wellbeing. Ray represents one of the 5% of patients that drive 70% of dollars spent in the health system, patients with multiple chronic health conditions at risk for hospitalization.

What if we could take better care of patients with complex needs while also saving money? Community Health Center Network (CHCN) with its 134,000 medical managed care patients across Alameda County launched a case management pilot, Care Neighborhood, to help patients like Ray while saving the health system hospital readmission and ER visit costs. A Care Coordinator connects with a patient who is cycling in and out of the ER, and together they complete a comprehensive health assessment and develop goals. The Care Neighborhood model incorporates several innovations:

– Design Thinking approach where patients help shape the model from the outset

– Focus on Social Determinants of Health (issues that affect health for the populations served, such as food insecurity, transportation, housing, violence, and trauma)

– Care coordination and Integration

– Community Partnerships through collaboration with Alameda County’s anti-poverty campaign, All-In

– Patient-led advocacy to ensure patient and community buy-in to bolster long-term sustainability of Care Neighborhood case management

– Health care cost control

Since joining Care Neighborhood, Ray has shown remarkable improvement. His inpatient days have decreased, his high blood pressure has dropped, his reported ability to control his health (PAM activation level) has gone up, and his depression is less severe.

He attributes success to his Care Coordinator, “Celina from Care Neighborhood is the best working person for me. She is past a 5. She has helped me with a lot of things. Even though Celina has her own workload, she makes time to talk to me. I suffer from depression and talking to her helps. She is extraordinary.”

CHCN is keeping patients involved involved in their health and connected to their “neighborhood” through an advocacy group called RESPECT. This group of Care Neighborhood participants meets on a monthly basis to work on self-identified advocacy issues. In sharing their views about health, the group has surfaced concerns that went beyond individual health needs to broader barriers to wellbeing like housing and transportation, and safety. The advocacy group becomes a space for mutual aid and community leadership, and their voices are amplified through the Alameda County All In initiative to tackle poverty.

Care Coordinator Angela O’Brien envisions a long-term role for the group, including Care Neighborhood leadership. “I’d like to see a Community Health Worker come out of the RESPECT group,” says O’Brien.

Launched in July 2014 Care Neighborhood pilots include LifeLong Medical Care and Axis Community Health and plans are in place to move to other community health centers in Alameda County. Community Health Center Network manages Care Neighborhood.

 

Far left image UFV  via Flickr: bit.ly/1UqD0VB