High-need Patients Research Articles

Inviting Ourselves to the Party: Cystic Fibrosis as a Model for Implementing Palliative Care Practice, Research, and Policy in "New Diseases” (FR439)

•Describe the opportunities and challenges involved in developing an outpatient palliative care clinic for patients with cystic fibrosis.•Describe a patient-centered model for developing a palliative care intervention in a disease population without much palliative care evidence, as well as the challenges in conducting clinical research in CF palliative care. Cystic fibrosis is a chronic, progressive, and fatal disease. Individuals living with CF suffer from myriad physical and psychosocial burdens that dramatically degrade patient and caregiver quality of life. Although the evidence base for palliative care in CF is scant, patients living with CF and their caregivers undoubtedly possess palliative needs. Yet, no established model of PC exists for this population of high-need patients. Distinctive characteristics of CF, such as its lifelong nature, unpredictable trajectory, advancing therapies that may alter the course of illness dramatically for some, and the complexities of lung transplantation merit evaluation of how PC should be designed for CF. CF is one of many underrepresented disease populations with palliative needs, yet without as strong an evidence base or clinical presence as other classic palliative care populations (e.g., oncology). This multidisciplinary, multi-institutional panel of clinicians and researchers in palliative care, pulmonology, and nursing will highlight opportunities and challenges of “breaking into” new disease populations, using CF as an exemplar. First, we will present a multi-pronged approach of identifying palliative needs in CF using qualitative methods and a nationwide survey, to aid in building support for and developing clinical programs. Second, we will describe the process and lessons learned during the development and conduct of the first clinical trial of palliative care in CF. Third, we will share insights on developing an outpatient CF palliative care clinic. Lastly, we will discuss our experiences with developing practice guidelines for palliative care in populations where need and enthusiasm exist, despite little evidence. Lessons learned in this session will be applicable to other fledgling populations with less established research and clinical presence from palliative care. Through shared learning, this forum will nurture future work to level the playing field so that all patients with life-limiting illness benefit from palliative care, regardless of disease.

Core Functions and Forms of Complex Health Interventions: a Patient-Centered Medical Home Illustration.

Despite policy and practice support to develop and test interventions designed to increase access to quality care among high-need patients, many of these interventions fail to meet expectations once deployed in real-life clinical settings. One example is the Patient-Centered Medical Home (PCMH) model, designed to deliver coordinated care. A meta-analysis of PCMH initiatives found mixed evidence of impacts on service access, quality, and costs. Conceptualizing PCMH as a complex health intervention can generate insights into the mechanisms by which this model achieves its effects. It can also address heterogeneity by distinguishing PCMH core functions (theintervention's basic purposes) from forms (thestrategies used to meet each function). We conducted a scoping review to identify core functions and forms documented in published PCMH models from 2007 to 2017. We analyzed andsummarized the data to develop a PCMH Function and Form Matrix. The matrix contributes to the development of anexplicit theory-based depiction of how an intervention achieves its effects, and can guide decision-support tools in the field. This innovative approach can support transformations of clinical settings and implementation efforts by building on a clear understanding of the intervention's standard core functions and the forms adapted to local contexts' characteristics.

A Retrospective Study of Administrative Data to Identify High-Need Medicare Beneficiaries at Risk of Dying and Being Hospitalized.

Developing a definition of what constitutes high need among Medicare beneficiaries using administrative data is an important prerequisite to evaluating value-based payment reforms. While various definitions of high need exist, their predictive validity for different patient outcomes in the following year has not been systematically assessed for both fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries. To develop a definition of high need using administrative data in 2014 and to examine its predictive validity for patient outcomes in 2015 as compared to alternative definitions for both FFS and MA beneficiaries. Retrospective cohort study of national Medicare claims and post-acute assessment data. All Medicare beneficiaries in 2014 who survived until the end of the year (n = 54,717,039). Two or more complex conditions, 6 or more chronic conditions, acute or post-acute health services utilization, indicators of frailty, complete dependency in mobility or in any activities of daily living in post-acute care assessments, hospitalization, mortality, days in community, Medicare expenditures. Based on our definition of high-need patients, 13.17% of FFS and 8.85% of MA beneficiaries were identified as high need in 2014. High-need FFS patients had mortality rates 7.1 times higher (16.23% vs. 2.27%) and hospitalization rates 3.4 times higher (40.69 vs. 12.03) in 2015 compared to other beneficiaries. Competing high-need definitions all had good specificity (≥ 0.88). Having 3 or more Hierarchical Chronic Conditions yielded a good positive predictive value for hospitalization, at 0.50, but only identified 19.71% of FFS beneficiaries hospitalized and 28.46% of FFS decedents that year as high need, as opposed to 33.92% and 51.98% for the new definition. Results were similar for MA beneficiaries. The proposed high-need definition has better sensitivity and yields a sample of almost 5 million FFS and 1.5 million MA beneficiaries, facilitating outcome performance comparisons across health systems.

Evaluation of the intensive outpatient clinic: study protocol for a prospective study of high-cost, high-need patients in the University of Utah Health system

IntroductionThe University of Utah (UofU) Health intensive outpatient clinic (IOC) is a primary care clinic for medically complex (high-cost, high-need) patients with Medicaid. The clinic consists of a multidisciplinary care...

The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale

BackgroundMedically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research.Methods/designParticipants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation.DiscussionThe SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers.Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858

Identifying target groups for person-centred integrated care among multi-morbid populations

Background The growing populations of people with multi-morbidity pose a new challenge to health systems. As multi-morbidity is not a clearly demarcated condition, chronic disease management programs may be unable to meet the needs of persons with multi-morbidity. This requires health systems to shift to more person-centred care models. Developing person-centred care for people with multi-morbidity asks for knowledge about their needs. Methods We conducted four studies (within the EU funded JACHRODIS and ICARE4EU project, and in a recent project funded by the Netherlands MoH) to gain insight in the needs of primary care patients with multi-morbidity. We distinguished subgroups based on their use of health services and quality of life by cluster analyses, and described their medical characteristics and resources (e.g., social support, health literacy, self-management abilities). Next, we predicted adverse outcomes, i.e., a poor quality of life and suboptimal use of services, from patients’ illness perceptions and resources by logistic regression analysis. Results In all studies, we found half of the study sample to report a relatively good quality of life and/or a low use of health services. The other half consists of various subgroups: with a poor QoL (physical and mental or social), a high or suboptimal use of health services or a combination of these outcomes. Adverse outcomes relate to medical characteristics, but also to persons’ perceptions of their conditions and resources. Conclusions Among multi-morbid populations, subgroups of high-need patients can be distinguished based on their medical complexity, illness perceptions and resources (e.g., health literacy, mastery). These subgroups differ in their needs for care and support, and thus require different integrated care arrangements, for instance, horizontal integration of primary care and social care, and/or vertical integration of primary and secondary care services. (aut. ref.)

Integrated Care for High-need High-cost Patients: The Comprehensive Care for Multimorbid Adults Program (CC-MAP)

Introduction : Multimorbidity, the co-occurrence of chronic conditions, is common and associated with substantial burden to patients and healthcare systems. Yet, evidence on the effectiveness of multimorbid primary care programs is limited. We aimed to describe the Comprehensive Care for Multimorbid Adults Program (CC-MAP) and report 12-month hospitalization, quality of life and quality of care outcomes. Methods : A cluster-controlled design of primary care clinics in Clalit Health Services, Israel's largest non-for-profit insurer and provider of services. A total of 1200 (600 in each arm) high-risk multimorbid patients were recruited for a study of primary care clinics participating in the intervention and in comparable, usual care, controls. Clinics with a high proportion of patients with high morbidity burden, measured by the Johns Hopkins Adjusted Clinical Groups (JH-ACG)® weighted score, where chosen for the intervention and similar clinics were chosen as controls . In each of the intervention clinics, a nurse collaborated with 3-4 primary care physicians (PCP) to care for the 100 highest-risk multimorbid patients. Nurses performed comprehensive assessment; designed an all-inclusive care plan; developed a patient tailored action-plan, provide integration of all services and care transitions, and provided self-management support, and care integration. The PCP collaborated with the CC-MAP nurse, mainly in regards to receiving information from the comprehensive assessment she performed and in the joint creation of the care plan and its follow-up. Unplanned hospitalizations, self-reported physical component score (PCS) and mental component score (MCS) of the SF-12v2, and quality of care (using the Patient Assessment of Chronic Illness Care, [PACIC]), were assessed 12 months after recruitment. Results : Patients in the control group were not significantly different from patients in the intervention in regards to clinical characteristics and prior hospitalizations. PCS and PACIC scores were significantly higher in the intervention versus controls (p Discussions : The CC-MAP provides an effective comprehensive approach to reduce unwarranted healthcare utilization and maintain physical status of multimorbid patients. Conclusions : The CC-MAP provides an effective approach to patient selection and care provision for multimorbid patients, resulting in improved care, physical quality of life and reduced unplanned admissions. The program was recently expanded and currently includes 12 clinics in 3 districts. Lessons Learned : This study demonstrates the key features of successful multimorbidity primary care management programs and principles of equitable high-risk multimorbid case selection. The mental health components of the intervention should be strengthened. Limitations : The health care setting in which the study was performed (a large, integrated type of health care delivery system) may not resemble other health care systems. Nonetheless, similar principles of comprehensive multimorbid care management may be generalized. Suggestions for future research : Future research should examine long-term patients’ outcomes, as well as the involvement of patient’s caregivers’ in this process.

Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients.

Programs to improve quality of care and lower costs for the highest utilizers of health services are proliferating, yet such programs have difficulty demonstrating cost savings. In this study, we explore the degree to which changes in Patient Activation Measure (PAM) levels predict health care costs among high-risk patients. De-identified claims, demographic data, and serial PAM scores were analyzed on 2155 patients from multiple medical groups engaged in an existing Center for Medicare and Medicaid Innovation-funded intervention over 3years designed to activate and improve care coordination for high-risk patients. In this prospective cohort study, four levels of PAM (from low to high) were used as the main predictor variable. We fit mixed linear models for log10 of allowed charges in follow-up periods in relation to change in PAM, controlling for baseline PAM, baseline costs, age, sex, income, and baseline risk score. Total allowed charges were derived from claims data for the cohort. PAM scores were from a separate database managed by the local practices. A single PAM level increase was associated with 8.3% lower follow-up costs (95% confidence interval 2.5-13.2%). These findings contribute to a growing evidence base that the change in PAM score could serve as an early signal indicating the impact of interventions designed for high-cost, high-needs patients.

1.55 Child Psychiatry Outpatient Nurse Case Management Services: A Retrospective Analysis of a Novel Patient Intervention

There is a disproportionate distribution of health care resources among child and adolescent psychiatry patients, and there have been limited interventions that have significantly reduced the resource utilization rate of high-need patients. One intervention that has shown promise is the use of nurse case management (NCM) service. Starting in 2013, the University of Iowa offered NCM service for high-needs patients. These services included weekly phone contact to target patients, illness and medication education, crisis management strategies, and interpersonal support.

Obesity Is Independently Associated With Higher Annual Burden and Costs of Hospitalization in Patients With Inflammatory Bowel Diseases

Approximately 15%-40% patients with inflammatory bowel diseases (IBD) are obese. There is an inconsistent association between obesity and IBD phenotype and course. We conducted a nationally representative cohort study to estimate and compare the burden, costs, and causes for hospitalization in obese vs non-obese patients with IBD. Using the Nationwide Readmissions Database 2013, we identified obese (based on administrative claims code) and non-obese patients who had been hospitalized at least once, from January through June 2013, and followed them for re-hospitalization until December 2013. We compared annual burden (total days spent in hospital), costs, causes, and outcomes of hospitalization between obese and non-obese patients after 1:1 propensity score matching. We identified 42,285 patients with IBD, of which 12.4% were obese. After propensity scorematching, we included 5128 obese and 5128 non-obese IBD patients in our analysis. Compared to non-obese patients, obese patients spent more days in hospital annually (median, 8 vs 5days) (P < .01), with higher hospitalization-related costs (median, $17,277 vs $11,847) (P< .01); this pattern persisted in subsets of high-need and high-cost patients. Compared tonon-obese patients, obese patients were more likely to be hospitalized with preventable admissions (19% vs 15%) or cardiopulmonary complications (16% vs 12%). In an analysis of data on patients with IBD from the Nationwide Readmissions Database 2013, we found obesity to be independently associated with higher burden and costs of hospitalizations. Strategies should be considered to target obesity as adjunctive therapy for patients with IBD.

Segmentation of High-Cost Adults in an Integrated Healthcare System Based on Empirical Clustering of Acute and Chronic Conditions.

High-cost patients are a frequent focus of improvement projects based on primary care and other settings. Efforts to characterize high-cost, high-need patients are needed to inform care planning, but such efforts often rely on a priori assumptions, masking underlying complexities of a heterogenous population. To define recognizable subgroups of patients among high-cost adults based on clinical conditions, and describe their survival and future spending. Retrospective observational cohort study. Within a large integrated delivery system with 2.7 million adult members, we selected the top 1% of continuously enrolled adults with respect to total healthcare expenditures during 2010. We used latent class analysis to identify clusters of alike patients based on 53 hierarchical condition categories. Prognosis as measured by healthcare spending and survival was assessed through 2014 for the resulting classes of patients. Among 21,183 high-cost adults, seven clinically distinctive subgroups of patients emerged. Classes included end-stage renal disease (12% of high-cost population), cardiopulmonary conditions (17%), diabetes with multiple comorbidities (8%), acute illness superimposed on chronic conditions (11%), conditions requiring highly specialized care (14%), neurologic and catastrophic conditions (5%), and patients with few comorbidities (the largest class, 33%). Over 4years of follow-up, 6566 (31%) patients died, and survival in the classes ranged from 43 to 88%. Spending regressed to the mean in all classes except the ESRD and diabetes with multiple comorbidities groups. Data-driven characterization of high-cost adults yielded clinically intuitive classes that were associated with survival and reflected markedly different healthcare needs. Relatively few high-cost patients remain persistently high cost over 4years. Our results suggest that high-cost patients, while not a monolithic group, can be segmented into few subgroups. These subgroups may be the focus of future work to understand appropriateness of care and design interventions accordingly.

Implementation of a Geriatric Patient-Centered Medical Home: the Geriatric Patient – Aligned Care Team (GeriPACT)

Abstract Context A Veterans Health Administration (VHA) patient centered medical home, the Geriatric Patient-Aligned Care Team (GeriPACT). Methods Plan-Do-Study-Act (PDSA) cycles regarding strategy, resource development, patient and caregiver experience of care, and clinical care process improvement. Stakeholder engagement for half-time operation with initial grant support for personnel who also had collateral duties. Tracking of operations data. Results The clinic population grew from 200 to 627 over a 7-year period. GeriPACT patients were frail with multiple co-morbidities, including a mean age 84, a 19.4% yearly hospitalization rate, and 12.2% died yearly. Collaborative team management of these complex patients reduced mean number of outpatient medications from 11 to 9, and the 30-day rehospitalization rate was 10%, approximately half the facility’s rate. Estimated yearly cost avoidance for GeriPACT was $1,963,243. Implementation of GeriPACT is impacted by limited availability of trained providers. Conclusion GeriPACT may be a cost-effective way to manage high-risk, high-need elderly patients. GeriPACT expansion and implementation in all facilities has been made part of the VHA regional strategic plan.

Engaging High-Need Patients in Intensive Outpatient Programs: A Qualitative Synthesis of Engagement Strategies.

Intensive outpatient programs address the complex medical, social, and behavioral needs of individuals who account for disproportionate healthcare costs. Despite their promise, the impact of these programs is often diminished due to patient engagement challenges (i.e., low rates of patient participation and partnership in care). The objective of this study was to identify intensive outpatient program features and strategies that increase high-need patient engagement in these programs. Qualitative study. Twenty program leaders and clinicians from 12 intensive outpatient programs in academic, county, Veterans Affairs, community, and private healthcare settings. A questionnaire and semi-structured interviews were used to identify common barriers to patient engagement in intensive outpatient programs and strategies employed by programs to address these challenges. We used content analysis methods to code patient engagement barriers and strategies and to identify program features that facilitate patient engagement. The most common barriers to patient engagement in intensive outpatient programs included physical symptoms/limitations, mental illness, care fragmentation across providers and services, isolation/lack of social support, financial insecurity, and poor social and neighborhood conditions. Patient engagement strategies included concrete services to support communication and use of recommended services, activities to foster patient trust and relationships with program staff, and counseling to build insight and problem-solving capabilities. Program features that were identified as enhancing engagement efforts included: 1) multidisciplinary teams with diverse skills, knowledge, and personalities to facilitate relationship building; 2) adequate staffing and resources to handle the demands of high-need patients; and 3) a philosophy that permitted flexibility and patient-centeredness. Promising clinical, interpersonal, and population-based approaches to engaging high-need patients frequently deviate from standard practice and require creative and proactive staff with adequate time, resources, and flexibility to address patients' needs on patients' terms.

Outpatient Complex Case Management: Health System-Tailored Risk Stratification Taxonomy to Identify High-Cost, High-Need Patients.

U.S. health systems, incentivized by financial penalties, are designing programs such as case management to reduce service utilization among high-cost, high-need populations. The major challenge is identifying patients for whom targeted programs are most effective for achieving desired outcomes. To evaluate a health system's outpatient complex case management (OPCM) for Medicare beneficiaries for patients overall and for high-risk patients using system-tailored taxonomy, and examine whether OPCM lowers service utilization and healthcare costs. Retrospective case-control study using Medicare data collected between 2012 and 2016 for Ochsner Health System. Super-utilizers defined as Medicare patients with at least two hospital/ED encounters within 180days of the index date including the index event. Outpatient complex case management. Propensity score-adjusted multivariable logistic regression analysis was conducted for primary outcomes (90-day hospital readmission; 90-day ED re-visit). A difference-in-difference analysis was conducted to examine changes in per membership per month (PMPM) costs based on OPCM exposure. Among 18,882 patients, 1197 (6.3%) were identified as "high-risk" and 470 (2.5%) were OPCM participants with median enrollment of 49days. High-risk OPCM cases compared to high-risk controls had lower odds of 90-day hospital readmissions (0.81 [0.40-1.61], non-significant) and lower odds of 90-day ED re-visits (0.50 [0.32-0.79]). Non-high-risk OPCM cases compared to non-high-risk controls had lower odds of 90-day hospital readmissions (0.20 [0.11-0.36]) and 90-day ED re-visits (0.66 [0.47-0.94]). Among OPCM cases, high-risk patients compared to non-high-risk patients had greater odds of 90-day hospital readmissions (4.44 [1.87-10.54]); however, there was no difference in 90-day ED re-visits (0.99 [0.58-1.68]). Overall, OPCM cases had lower total cost of care compared to controls (PMPM mean [SD]: - $1037.71 [188.18]). Use of risk stratification taxonomy for super-utilizers can identify patients most likely to benefit from case management. Future studies must further examine which OPCM components drive improvements in select outcome for specific populations.

Factors associated with the receipt of documented evidence-based psychotherapy for PTSD in VA

The VA has mandated that evidence-based psychotherapies (EBPs) be offered to patients with PTSD, but only a small minority of the psychotherapy delivered to VA patients with PTSD is a documented EBP. It is unknown what factors are associated with receiving a documented EBP. Patients who received an EBP in FY2015 that was documented using a templated progress note (N = 21,808) were compared with patients who received psychotherapy for PTSD that was not documented using a template (N = 251,886). Among psychotherapy recipients, VA patients with markers of clinical complexity such as service connection for PTSD, comorbid bipolar or psychotic disorder, longer duration of PTSD diagnosis, and a benzodiazepine prescription for PTSD had lower odds of receiving a documented EBP. Recipients of documented EBPs differed from those who did not receive documented EBPs on several sociodemographic characteristics and indicators of treatment need. A limitation of our study is that some individuals in the group without EBP documentation may still have received an EBP, but did not receive EBP documentation in the electronic health record. Nevertheless, our results suggest that high-need or complex VA patients with PTSD may be less likely to receive documented EBPs.

特別養護老人ホームの介護職からみた看護職との連携と施設属性・看護体制・医療依存度の高い入所者の看護職の対応状況との関連

特別養護老人ホームの介護職からみた看護職との連携と施設属性・看護体制・医療依存度の高い入所者の看護職の対応状況との関連

Impact of a complex chronic care patient case conference on quality and utilization.

There is need for effective venues to allow teams to coordinate care for high-risk or high-need patients. In addition, health systems need to assess the impact of such approaches on outcomes related to chronic health conditions and patient utilization. We evaluate the clinical impact of a novel case conference involving colocated trainees and supervisors in an interprofessional academic primary care clinic. The study utilized a prospective cohort with control group. Intervention patients (N = 104) were matched with controls (N = 104) from the same provider's panel using propensity scores based on age, gender, risk predictors, and prior utilization patterns. Clinical outcomes and subsequent utilization patterns were compared prior to and up to 6 months following the conference. In terms of utilization, intervention patients demonstrated increased visits with primary care team members (p = .0002) compared with controls, without a corresponding increase in the number of primary care providers' visits. There was a trend towards decreased urgent care and emergency visits (p = .07) and a significant decrease in the rate of hospitalizations (p = .04). Patients with poorly-controlled hypertension saw significant decreases in mean systolic blood pressure from 167 to 146 mm Hg. However, there were no differences between the intervention and control groups. Intervention patients with diabetes demonstrated a nonsignificant trend towards decreased hemoglobin A1c from 9.8 to 9.4, when compared with controls. Interprofessional case conferences have potential to improve care coordination and may be associated with improved disease management, decreased unplanned care, and overall reduced hospitalizations.

A Network Analysis Perspective to Implementation: The Example of Health Links to Promote Coordinated Care.

Although implementation models broadly recognize the importance of social relationships, our knowledge about applying social network analysis (SNA) to formative, process, and outcome evaluations of health system interventions is limited. We explored applications of adopting an SNA lens to inform implementation planning, engagement and execution, and evaluation. We used Health Links, a province-wide program in Canada aiming to improve care coordination among multiple providers of high-needs patients, as an example of a health system intervention. At the planning phase, an SNA can depict the structure, network influencers, and composition of clusters at various levels. It can inform the engagement and execution by identifying potential targets (e.g., opinion leaders) and by revealing structural gaps and clusters. It can also be used to assess the outcomes of the intervention, such as its success in increasing network connectivity; changing the position of certain actors; and bridging across specialties, organizations, and sectors. We provided an overview of how an SNA lens can shed light on the complexity of implementation along the entire implementation pathway, by revealing the relational barriers and facilitators, the application of network-informed and network-altering interventions, and testing hypotheses on network consequences of the implementation.

Wellness Care Plans: An innovative approach for high-needs healthcare users

Healthcare organisations are continually looking for ways to address the needs of ‘high utilisers’ of their systems. Southcentral Foundation (SCF), an Alaska Native customer-owned healthcare system located in Anchorage, Alaska, employs an innovative approach to working with these patients (who are called ‘customer-owners’ at SCF). SCF does not restrict these customer-owners from accessing the healthcare system; rather, SCF works with these customer-owners to create a Wellness Care Plan to help them reach health goals they and their primary care provider set while working together with a behavioural health consultant. Once goals have been set, the customer-owner’s integrated care team handles follow-up, and the plan is noted at the top of the customer-owner’s Electronic Health Record (EHR) so that any other providers they see have easy access to it. Goals and action items are tracked in the EHR and collated in SCF’s Data Mall. Data are also tracked on the number of reactive and proactive visits the customer-owner makes, to help their care team evaluate the effectiveness of the Wellness Care Plan. SCF has seen increased rates of healthcare quality for customer-owners on Wellness Care Plans, which indicates that a collaborative approach to working with high-needs patients can achieve positive results when the system works to support this kind of approach. Studying SCF’s Wellness Care Plans may prove valuable for other healthcare organisations struggling to help high-needs patients.

The Max Clinic: Medical Care Designed to Engage the Hardest-to-Reach Persons Living with HIV in Seattle and King County, Washington.

The Max Clinic in Seattle, Washington is designed to engage patients who have extensive barriers to HIV care. In this article, we describe the clinic's evolution and outcomes of patients enrolled in the first 2 years. The clinic is a high-intensity, low-threshold, incentivized care model that includes walk-in access to primary care in a Sexually Transmitted Disease Clinic. Patients who have failed to engage in care and achieve viral suppression with lower intensity support are referred by clinicians, case managers, and the health department Data to Care program. The clinic offers food vouchers, cash incentives, no-cost bus passes, and cell phones, as well as intensive case management with cross-agency coordinated care. The primary evaluation outcome was the percentage of patients who achieved viral suppression (HIV RNA <200 copies/mL) at least once after enrollment. Secondary outcomes were continuous viral suppression (≥2 suppressed results in a row ≥60 days apart) and engagement in care (≥2 completed medical visits ≥60 days apart). During January 2015-December 2016, 263 patients were referred; 170 (65%) were eligible, and 95 (56% of eligible) were enrolled. Most patients used illicit drugs or hazardous levels of alcohol (86%) and had diagnosed psychiatric illness (72%) and unstable housing (65%). During the year after enrollment, 90 (95%) patients engaged in care. As of the end of 2016, 76 (80%) had achieved viral suppression, and 54% had continuous viral suppression. The Max Clinic successfully treated HIV in high-need patients and, to date, has been sustainable through a combination of federal, state, and local funding.