The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Category: Uncategorized (page 1 of 4)

Addressing social determinants through integrated care

Deby Evans

Deb Evans is the MVC Site Engagement Manager

Despite being one of the world leaders in medical care and research, the United States (U.S.) spends the most amount of money on healthcare, yet better patient outcomes are subject to debate. Not only do physical ailments and mental health disorders affect the health of the population, but social determinants, such as environmental factors, education and transportation availability, also play a prominent role in determining health outcomes. The U.S. healthcare system has typically focused on providing care for physical conditions and diagnoses, yet many patients may have a secondary behavioral health condition. In addition, all patients have their own specific set of social determinants that should be taken into consideration when providing healthcare. These factors ultimately impact behaviors and health outcomes of individuals.

A white paper published by Deloitte Consulting discusses the implications of social determinants on patient outcomes and healthcare costs. It encourages us to seek out and investigate methods to provide more integrated patient care within hospital systems and the U.S. healthcare system as a whole.

Addressing social determinants is a challenge for healthcare providers but a necessary one to help improve patient outcomes along with the added benefit of reducing costs. Some of the ways hospitals can respond to this challenge is by implementing coordinated care, care management or integrated care programs. However, despite varying existing program models, each type brings its own barriers with accessibility, communication and information management being the most complex. By working through these barriers and integrating care for patients, hospitals have the potential to not only affect patient outcomes but also reap the benefits of controlling costs. Rush University Medical Center, for example, is using a tool in their emergency department that allows them to screen for social and structural determinants of health. When used in conjunction with a recently instituted community health needs assessment and the community health implementation plan, this method helps address healthcare disparities in the local neighborhoods and brings positive changes to their patient outcomes.

For more information on the Deloitte paper: https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/social-determinants-and-collaborative-health-care-for-plans-and-states.html

For more information on Rush University Medical Center: http://www.hhnmag.com/articles/8441-rush-university-medical-center-targets-community-health-disparities or https://www.rush.edu/sites/default/files/community-health-implementation-plan.pdf

 

Managing High-Needs Patients can Help Improve Outcomes at Michigan Hospitals

Abeer Yassine

Abeer is the MVC Hospital Engagement Associate

Only about 5% of patients are considered high-need, yet these patients constitute nearly 50% of total healthcare costs. High-need patients typically have more complex diagnoses and significant barriers to accessing healthcare that impacts the self-management of their condition(s) outside of the hospital. In a recent, pre-publication report, Effective Care for High-Need Patients, the National Academy of Medicine (NAM) outlines various characteristics of high-need patients, patient taxonomy models, along with care models. This report is a compilation of feedback from relevant workshops, presentations, discussions, and literature and stresses the importance of identifying and managing care delivery to high-need patient populations.

High-Need Patients Characteristics

To better create targeted initiatives in a hospital setting for high-need patients, there needs to be better identification of characteristics using data. Although there is not one, specific definition of “high-need patients”; functional limitations, complexity of care/disease, and health care costs are all characteristics that can be used to identify and analyze these patient populations. These characteristics not only impact the care that is delivered within the clinical setting, but also the ability for that patient to self-manage their health outside of the hospital.

High-Need Patient Taxonomies

NAM reviewed two patient taxonomy models in use by the Harvard T.H. Chan School of Public Health and The Commonwealth Fund to better segment patients for improved identification of high-need populations. Using a taxonomy model can guide health systems to more suitable integration of behavioral, social, and functional characteristics in the patient care plan outside of the clinical setting. What is unique about the taxonomy developed by NAM is that it builds upon clinical and medical characteristics to identify behavioral health and social factors that affect care delivery decisions. More detail about this starter taxonomy and a conceptual model can be found here.

Successful Care Models for High-Need Patients

This NAM report also uncovered common characteristics among care models that are successful in managing high-need patient populations. The report mentions that successful care models typically expand upon domains related to health and well-being, care utilization, and costs. Furthermore, these care models include details on dimensions related to service setting focus, care attributes, delivery features, and organizational culture. By targeting a specific high-need patient population (ex: age group), health systems are better able to create care models and initiatives geared towards improved, more integrated care delivery. The report also outlines an analytic framework that helped NAM identify successful care models for high-need patients.

The MVC Coordinating Center can help member hospitals identify domains and care utilization of high-need patients.  If you are interested in identifying these populations within your hospital, please reach out to Deby (debevans@med.umich.edu) or Abeer (abeery@med.umich.edu).

Interested in learning more about optimizing care delivery for high-need patient populations? More information and a copy of Effective Care for High-Need Patients can be found below:

https://nam.edu/effective-care-for-high-need-patients/

https://nam.edu/wp-content/uploads/2017/06/Effective-Care-for-High-Need-Patients.pdf

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