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Rethinking the Complex Engagement Model
It was the tenthtime Mary had presented to the emergency department (ED) suicidal and intoxicated after trying to subvert her depression with alcohol. This time, a caring bystander had called 911 as they saw her laying on the sidewalk mumbling and the ambulance had brought her to the one place that was open after hours—the ED.
Mary’s story is not unique; research shows that roughly one in four Americans suffer from a diagnosable mental illness. When complicated by other psychosocial conditions such as substance abuse, homelessness, or chronic medical conditions, our country’s medical care system can be disheartening to navigate. All too often, this leads to poor preventative care, and eventually higher incidences of crisis events such as Mary’s. One term used to describe patients at such risk is “complex care patients.” Our current system of care for complex care patients isn’t working; a new approach is needed—one that accounts for these conditions and better leverages in-person connection to address them.
Complex Patient Engagement: The Problem With Our Current Approach
A large percentage of complex care patients struggle with psychosocial issues, with data showing that over one third are homeless, over 40% struggle with mental health issues, and over half have some form of substance use disorder.
While resources to address these challenges have increased over the last decade, finding and engaging complex care patients remains one of the most difficult hurdles for organizations hoping to serve them. As a result, although money is being spent on infrastructures meant to address the social determinants of health and mental health conditions prevalent in our communities, the most marginalized of these patients remain untouched and ultimately, people like Mary end up in the ED instead. Typically, these patients represent 2-3% of the population, but over 25% of the health care dollars currently being spent in our country.
Bridging Patient Engagement Gaps With Personal Connection
While payer organizations have been identifying high-cost, complex patients for years, many of their programs of care have been limited only to communication through validated information such as known phone contacts or emails. However, patients struggling with complex conditions like homelessness, substance abuse, and mental health issues may not respond to traditional outreach efforts. They may not have phones or have phone numbers listed that are no longer valid. Furthermore, these individuals may distrust the health care system—leaving them skeptical to enter dialogue and uninterested in trying to navigate a difficult-to-access health care.
Engaging patients, then, begins with restoring trust in the provider, in the community, and in the health care system as a whole where it has been previously lost. This requires a direct and frequent in-person approach.
In Mary’s case, we viewed her frequent ED visits as an opportunity for engagement. Through real-time software that notified our staff every time Mary was admitted, discharged, or transferred from any ED in the area, we were able to reach out to Mary during her ED visits. We inform her of the psychosocial and additional community resources we could connect her with. The first 9 times we called Mary refused our services. But our persistence paid off on her 10th visit—she had grown to trust us enough to accept our help.
The Power of Collaboration: Creating Communities That Work to Better Support Patients With Complex Needs
Once patient trust has been established, successful complex care management programs will utilize connections developed between multiple stakeholders to offer a holistic, rounded approach to keeping each patient on the track to better health. In working directly with patients, we can better Identify and address the gaps in service occurring in their lives and address those gaps before additional crisis events occurred. Often, the most pressing needs for patients are quite different than what we have imagined. Being able to better identify and address these as soon as possible, we can increase our patent’s trust in our abilities to serve them.
Complex patients typically touch multiple community resources. Ideal support for patients with complex care needs requires collaboration between all of these resources, including hospitals, health clinics, EMS, law enforcement, housing authorities, jails, behavioral health and chemical dependency centers. To effectively engage patients where they are and break the patterns of utilization and readmission with better, community-based resources. Unfortunately, these voices are rarely in dialogue with each other, leading to frequent duplication of efforts across the care community, mixed messages for the patient, and augmented frustration in navigating an already fractured health care system.
With the proper approach and tools, coordination across the community of care can be successful. The approach is complex, but with over 15 year’s experience in creating and implementing such models of care, I can vouch that models, such as those we implement at Community Based Coordination Solutions (CBCS), make a consistent difference, changes lives, and can do so in a cost-saving manner.
How Can We Best Engage Hard-to-Reach Complex Patients?
To be successful in complex care patient engagement, we have to make it easier for even the most vulnerable patients to connect. While we can start with phone calls, text messaging, and emails as a way to engage patients, we cannot stop there.
Successful patient engagement programs are willing to escalate outreach efforts—including home visits and, in communities that have strong health information exchange (HIE) programs, real-time visits during crisis events. Such programs are game-changers in engaging hard-to-reach complex patients.
Outreach during crisis events can be particularly effective requires committed planning. Many of these events occur “after hours” and is most effective when program staff are available around the clock.
While crisis moments are NOT the time to conduct a full intake assessment, they are opportunities to meet the patient, learn more about their issues of concern, offer insight into how we can help them address these issues, and confirm appropriate contact information to meet in 1-2 days in a less intense environment to begin working together.
Our intake assessments are typically 3–4-hour events, and we provide our staff with Immediate Access Funds they can use in to provide needed resources to the patient during that crisis event. By addressing immediate needs such as phones, clothing, food, or even housing, trust begins, and patient engagement increases.
As we are persistent in connecting each patient with the appropriate medical and community resources following a crisis—making it as easy as possible for patients to engage with us—that trust is solidified. As was the case with Mary, consistently being there for her meant that, when she was ready to engage, we were there.
What Are the Results?
CBCS has shown dramatic results with this approach—demonstrating 80% patient engagement with a cohort that our organizational partners have had little to no success in engaging. Our programs have also resulted in dramatic cost savings for our partner organizations with 40% or higher reduction in costs within year 1 of program implementation—covering program costs and providing a net revenue for partners.
In addition, many patients remained engaged with community and social workers and transition lesser acute programs within 2 years and have become much more engaged with their health care issues.
In Mary’s case, she completed a 7-day detox program, a 90-day alcohol recovery program, and found long-term housing. Within a month of leaving her finishing her 90-day recovery program, she had a job and was spending time volunteering to support other complex patients. She has relapsed, but even within her relapses has remained engaged and has demonstrated steady progress towards long-term improvement.
Where Can We Go With This? Principles for Moving Forward
The patient engagement efforts we utilize at CBCS have been successfully proven across multiple communities of care—from urban to rural to metropolitan—yielding a few key principles for success:
- To be most effective, staff should be available 24/7
- Funds must be available to staff help address certain immediate patient needs as recognized
- Strong, real-time HIEs across the community of care are effective in allowing social and community workers to engage with patients during crisis moments
With these tools, and by engaging in common dialogue with the various community resources that touch the lives of our complex care patients, we can create a common system of care in any community in our country that is cost-effective AND provides much more effective health care to the most challenging patients in our communities.
Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of the Population Health Learning Network or HMP Global, their employees, and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, or anyone or anything.
