Innovative Care Management Program Avoids Nearly $16M in Costs and Transforms Lives of Super-Utilizers

女王医疗中心(QMC)是近60%无家可归者到急诊(ED)就诊的地方，有些人每天都到急诊。不同数量的资源用于治疗这些患者，他们本可以在急诊室之外得到更好的照顾。为了改善患者结果和降低成本，女王卫生系统开发了一个项目，以改善这一独特的患者群体的结果，利用其分析平台，支付人数据和患者流量数据来评估系统的成功和效率。世界杯厄瓜多尔vs塞内加尔波胆预测

HEALTH INEQUITIES LINKED TO HOMELESSNESS

Nationwide, patients who are homeless visit the ED at a rate 4.8 times higher than patients who are not homeless, and people who are homeless die 12 years earlier than the general U.S. population.¹无家可归者的慢性健康状况因经常接触传染病、暴力和营养不良而恶化。²Homelessness is associated with health inequities, and care management is often needed for patients who are homeless. Hawaii’s homelessness rate is the second-highest in the nation.

ED SUPER-UTILIZERS CONSUME DISPARATE RESOURCES

Nearly 60 percent of all ED visits at QMC were patients who were homeless. Some patients visited the ED every day. These super-utilizers—patients with 15 or more ED visits in a quarter, three admissions to QMC in a quarter, or 15 days of hospitalizations in a quarter—were consuming a disproportionate share of resources and had needs that could be better met outside the ED.

QHS had enrolled these patients into its programs for high utilizers but had not achieved the positive impact on patient outcomes, costs, and patient experience that it desired. The organization needed a new care management strategy that would allow it to respond to the needs of this unique patient population more effectively.

CARE MANAGEMENT IMPROVES PATIENT OUTCOMES AND REDUCES COSTS

QHS developed the Queen’s Care Coalition, an innovative care management program, to address the needs of super-utilizers. In addition to utilization criteria, QHS screens patients for social determinants impacting health outcomes, including employment, food insecurity, housing instability, poverty, incarceration, and violence. When QHS finds patients with multiple factors influencing their health and wellbeing, it enrolls the patients in the care management program.

社区卫生工作者首先在这些高需求、高费用的病人在急诊科或住院期间接触他们。建立信任关系后，卫生工作者为这些患者提供密集的出院后导航30至90天。卫生保健员拒绝对与他们合作的病人作出判断，并采取以力量为本、减少伤害的方法来改善病人的健康。

社区卫生服务人员每周会见病人一至三次。会议可以在公园、人行道、无家可归者的营地举行——任何病人可能在的地方。卫生工作者与患者一起工作，以满足对他们来说最重要的目标和需求。病人不需要停止使用药物来接受服务，也不会因为错过预约而受到处罚或被从护理管理项目中除名。

社区卫生工作者将患者与医疗和行为健康服务以及社区服务联系起来，以确保患者在正确的地方获得正确的护理，并防止无意的重复服务。卫生保健员安排和参加与病人的医疗、行为健康和福利预约;协助财务和非财务利益申请;将患者连接到低屏障住房/庇护所;并提供技能培训以培养独立性。当病人准备好时，社区卫生工作者会向社区伙伴进行热情的交接。社区卫生服务人员会在六个月的时间里与病人复诊，如果病人需要额外的服务，他们会再次与病人接触。

QHS leverages the Health Catalyst^®数据操作系统(DOS™)平台的数据和分析。世界杯厄瓜多尔vs塞内加尔波胆预测Queen 's Care Coalition患者的住房状况数据被输入到即时数据输入应用程序(IDEA)中，确保数据可以随时用于DOS分析和报告。该组织能够使用支付者数据、患者数据和患者流量数据进行持续的项目评估和基于数据的决策。

RESULTS

女王护理联盟正在改变人们的生活，同时降低利用率和成本。QHS achieved the following results:

• $16M in costs avoided, the result of a:
  • 68.5 percent relative reduction in the number of days patients spent hospitalized.
  • 22.8 percent relative reduction in length of stay.
  • 43.8 percent relative reduction in readmission rate.
  • 700 fewer ambulance transports, freeing up ambulances for medical emergencies.
  • 1,425 fewer ED visits, improving ED capacity for patients in need of emergency care.
• 61 percent of patients who were homeless at program enrollment had secured housing when discharged from the program.
• Improved care coordination positively impacted the payers’ costs for patients enrolled in the program. The total cost of care incurred by payers was reduced by $624K during the three six-month periods after patient enrollment in the Queen’s Care Coalition program.

一名患者的生活因女王护理联盟项目而改变，她在三个月内使用ED 16次，其中4次住院治疗。该患者在一个停车场住了10年，有精神健康诊断和药物滥用史。他缺乏与社区资源的联系，拒绝接受心理健康和药物滥用治疗。He was not consistently taking his prescribed medications.

QHS enrolled the patient in the Queen’s Care Coalition program. The patient’s CHW:

• Provided intense navigation for 30 to 90 days, helping the patient recognize strengths and establish goals.
• Assisted the patient in obtaining a short-term medical respite bed.
• Attended the patient’s appointments with him.
• Aided him with signing up to receive food stamps and Social Security.
• 帮助病人改善卫生条件，获得永久住所。
• 安顿好后，带他去杂货店买菜，教他做饭。

After three months, the patient graduated from the program. He remains housed, attends his medical appointments on his own, and takes all prescribed medications. He has not returned to the ED for more than two years.

Queen’s Care Coalition has improved health equity and transformed lives. We have seen people who were homeless and routinely assaulted reshape their lives. They’re now living independently, going to their medical appointments, adopting pets—living full, healthier lives.

– Ashley Shearer, LCSW, CSAC, Manager, Queen’s Care Coalition

WHAT’S NEXT

QHS计划扩大女王医疗联盟，并将其项目扩展到整个医疗系统，扩大其覆盖范围和能力，在降低医疗成本的同时改变更多的生命。

REFERENCES

1. QuickStats: Rate of Emergency Department (ED) Visits, by Homeless Status and Geographic Region — National Hospital Ambulatory Medical Care Survey, United States, 2015–2018. (2020).Morb Mortal Wkly Rep, 69(50). Retrieved fromhttps://www.cdc.gov/mmwr/volumes/69/wr/mm6950a8.htm
2. Homelessness & Health: What’s the Connection? Fact Sheet. (2019).全国无家可归者保健委员会Retrieved fromhttps://nhchc.org/wp-content/uploads/2019/08/homelessness-and-health.pdf