Lauran Hardin, MSN, CNL, FNAP, FAAN* and Mark Humowiecki, JD, Camden Coalition’s National Center for Complex Health and Social Needs
Most health systems serve a population of people without insurance — even in states that expanded Medicaid.
Without insurance, people experience difficulties accessing needed services to meet physical and behavioral health needs. Lack of insurance typically goes hand-in-hand with other unmet social needs like food insecurity and lack of housing. People who are uninsured often have significant complex health issues that result in high rates of hospitalization and emergency department (ED) visits, thereby increasing costs and decreasing patient’s health and well-being. Many hospital systems are seeking strategies to care for this population to both support the best outcomes for the patient as well as ensure the viability and long-term sustainability of such a program. One such success story is the ONE Health program at Regional One Health in Memphis, Tennessee, which focuses on uninsured individuals and created a strong value case for consistent investment in addressing their needs.
Regional One Health is the largest safety net provider in Memphis, serving the tri-state area of Tennessee, Mississippi, and Arkansas as a regional burn and trauma center. Tennessee did not expand Medicaid and more than 30 percent of the people accessing the hospital lack insurance. In 2016, the health system launched the ONE Health program to comprehensively serve the needs of uninsured community members with complex health and social needs.
The ONE Health team includes four registered nurses, three social workers, a data analyst, and a complex care clinical director who is also a nurse. Anchored in a clinic in the outpatient area of the hospital, they round daily in ED and inpatient units to connect to new and existing patients, hold appointments in the clinic, round at a complex primary care office, and travel to community agencies with clients. They care for a population of more than 700 patients and continue to monitor clients even after graduation to re-engage if a new pattern of instability or crisis emerges.
The team uses an algorithm to identify potential clients on a daily basis in the ED and the inpatient unit, and receives direct referrals from clinicians in the community. ONE Health also partners with community organizations to collaborate in care delivery and accepts direct referrals from behavioral health and homeless service providers.
ONE Health clients are 50 years old on average and have three to five chronic conditions. Social needs are prevalent in the population, with 25 percent experiencing homelessness on admission, 94 percent experiencing food insecurity, 47 percent with complex behavioral health issues, and 42 percent with substance use disorder.
The ONE Health team completes a comprehensive assessment upon admission to the program to provide insight into the medical, behavioral, social, and system drivers of the client’s needs. They use the Arizona Self-Sufficiency Matrix to identify social needs and create a benchmark to show improvement in self-sufficiency. The team has a process to identify whether an RN or social worker is best positioned to lead on the case based on the client’s issues. They also have a triage tool to identify cadence of visits based on the client’s level of need and they shift the number of visits as issues are resolved. The team is flexible with where they engage and meet with clients including clinic visits, co-visits with their primary care provider, at the bedside in ED, and inpatient as well as at local community agencies. Clients are followed on average for three to six months, but length of time is driven by the degree of self-sufficiency that has been attained. Graduation occurs when the client has a stable connection to care and stabilization in their health-related social needs.
ONE Health staff find people that might qualify for the program through a daily report driven by an algorithm for eligibility for services. The team uses this report daily to engage people in the ED or inpatient and also reach out by phone to offer the program. There is no charge for the services and the team collaborates with the patient’s current care team if they have one. About 80 percent of eligible patients agree to the service, and about 20 percent disenroll without completing the program.
The team works on building an authentic healing relationship with the client, as trust is key in the population. Many have had a lifetime of traumatic experiences and distrust the system. Partnering with the client and having them drive what is most important to address first is central to the approach. Megan Williams, MSN, CNL, Complex Care Director, leads the program and noted, “This is key to our ability to generate outcomes — starting from a place of respect and person-centered choice. The population deserves this — and it results in some pretty dramatic life changes and results.”
It’s a dangerous situation for a diabetic to be uninsured, homeless, and have food insecurity. Combined with poor access to medical care and lack of social support and housing, it’s a recipe for disaster. Patients often begin making regular emergency visits to Regional One Health to address both medical and social needs. It was after one of those ED visits that one particular patient met Porshure Richardson, a medical social worker with Regional One Health’s ONE Health complex care program.
The patient had been admitted to the hospital and was being discharged. His health was temporarily stable, but Richardson quickly realized that wouldn’t continue if he left without support. “There is a gap between someone being healthy enough to be discharged and being able to stay stable. In this patient’s case, he still wasn’t able to pay for his medications, food, or a place to live. He still needed help.” Meanwhile, she looked to ONE Health’s community partners to help with other needs. Richardson was able to find him housing, have medically tailored meals delivered to him, and follow his medical needs. As his physical health improved, he began focusing on healing in other parts of his life. “I had substance addiction issues, and I burned some bridges with my family,” he said. “They’re willing to help me now that they see I’m trying to help myself.” He is reconnecting with his children and grandchildren. “I’m grateful to Porshure. She saw I was trying to do the right thing, and she was there for me. When I saw it was working, I trusted her. I know people have been through so much that it’s hard to trust, but I advise anyone in this situation to try. They will help you.” For Richardson, it’s an inspiring outcome: “At first, he was just trying to survive day-to-day. Now, he’s able to focus on taking care of his health and I’m so proud of him.”
The ONE Health team has served over 700 patients with impressive outcomes. In partnership with Regional One’s chief financial officer (CFO), the ONE Health team creates monthly reports on the impact of the program. Admissions decreased by 56 percent in the population and ED visits decreased 40 percent one year after intervention. By meeting patient needs, coordinating care across settings and partnering in delivery, the team was able to decrease total cost in the population by 53 percent and variable cost by 49 percent. Getting insurance and disability benefits for people who qualified resulted in an increase in revenue of nine million dollars for the population. Doing the right thing also resulted in more efficient care, in the right setting, and a financial return that creates a return on investment greater than 25 percent for the program.
In addition, their outcomes include important shifts in quality of life and resources for the people they serve. 88 percent of participants experienced increased connection to a primary care home, 60 percent experienced stabilization in housing, 90 percent accessed food benefits, and 50 percent of participants accessed behavioral health services. These are some of the outcomes that matter most to the clients they serve.
Partner with finance.
Initiating a program that does not include a contract for revenue (either through billing or through a payer relationship) can be challenging in our current economic environment. ONE Health started with a strong partnership with the CFO to identify the population of interest and the measures they should focus on, as well as build out the reports needed to show the impact on the organization’s economics. The CFO helped the team to see that their impact on variable costs, like length of stay in the hospital or reduction in pharmacy costs, play a significant role in making the value case in addition to reducing overall unnecessary utilization.
Build partnerships to expand the reach of the care team.
Rather than displacing existing services in the community, the ONE Health team completed asset mapping to identify who they could partner with to deliver services. As clients identified needs, the team continued to build additional pathways and partnerships to help the individual, but also address needs of the population as a whole. For example, rather than adding behavioral health or housing navigation staff to their core team, they built a co-delivery pathway and regular case conferencing process with local agencies who already provided this service.
Partnering keeps costs low in the program and contributes to building a stronger network of services permanently in the community. Collaborating to meet the needs allows each agency to bring their best resources to the table and resolve issues quicker for clients.
Create a 360-degree view of impact.
The ONE Health team has several stakeholders including internal leaders (CFO, CEO, Board Members), community partners, philanthropists, government and social services. In order to make a strong case that mattered to each of these diverse groups, the team created a value case that includes cost, utilization, quality, satisfaction, and equity measures. Their measures can be found in this value case summary, which was developed as part of the Building the Value Case for Complex Care Toolkit from the National Center for Complex Health and Social Needs. In addition, with patient permission, they record client stories and share them broadly with their stakeholders. This allows people to hear directly from the consumers what matters most about the program and what the real value case is in delivery.
“Every Memphian deserves good health care — especially those without insurance.” said Susan Cooper MSN, Senior Vice President and Chief Clinical Integration Officer at Regional One Health. “We were spending our energy providing the wrong kind of care. And we’re learning that if you focus more on the preventive health side, people tend to need a lot less on the direct care side — and that’s a value equation that works for everyone.”
In the Field: Spotlight on Complex Care Interventions
This Better Care Playbook blog post series spotlights how organizations are implementing evidence-based and promising innovations to improve care for people with complex health and social needs. For organizations seeking to develop or enhance complex care programs, it is valuable to see how peers in the field are rethinking approaches to care. VIEW THE SERIES
*Lauran Hardin recently moved to a new position as Senior Advisor at Illumination Foundation and National Health Care & Housing Advisors.