I’ve long found the Camden Coalition of Health Care Providers model to be both innovative and compassionate. So the results of the recent study (1) showing limited impact from their intervention were disappointing. But they get to how working with high utilizers can be challenging both for health care providers and their funders.
First, a quick summary. For those unfamiliar with the Camden Coalition model, Executive Director Kathleen Noonan summarizes it here in a piece in Health Affairs (1):
“We identify individuals who return to the hospital again and again, receive care, but never get well. Like Sarah, our patients have multiple chronic conditions exacerbated by and layered atop lifetime burdens of housing instability, food insecurity, low literacy, and social vulnerability. Add to that societal challenges such as poverty, racism, and disinvestment, and these patients are left with few resources to self-advocate and heal…
… just 1 percent of all patients accounted for 30 percent of the area’s health care spending. Indeed, many of the patients we identified had more than 100 visits to the emergency department annually. We suspected that their outlier status as high utilizers would mean that even modest additional intervention could yield measurable return…
…Alongside leaders and clinicians from across Camden, we made underserved populations our focus—to increase their use of preventative care and social services and to reduce health care costs.”
I admire the focus here on using data to identify areas for improvement, but pairing that with a personal approach that involves working directly with high utilizers to help them get to appointments or address other day-to-day challenges. It’s a compassionate model.
But, a high-quality study did not show reduction in hospital visits. Noonan describes it saying (1):
“Even with increased use of services such as Supplemental Nutrition Assistance Program benefits and primary care engagement, patients in the intervention groups were readmitted to the hospital at similar rates to those in the control group.”
Noonan rightfully points to the idea that we need better ways to measure these types of programs. But there’s more here that points to how challenging this work is in the context of existing systems. The Camden Coalition sits amid an entire system of health care providers and social workers. In many ways the model is to integrate high utilizers into systems through a personal touch.
But how long should that effort by the staff at the Coalition last? It’s expensive to help high utilizers show up to their appointments, to ensure they are working with the right health care providers rather than the hospital system.
Here, the Coalition runs into a wider challenge. Funders have often put time limits on such interventions. Specifically, the Coalition has changed the model of how long it provides these services because of specifications from grants. That requires “handing off” the folks they’re working with to other parts of the health care system. If I had to speculative, one of the potential reasons for the disappointing results was likely that funding restrictions limited the overall timing that high utilizers were in the system was shortened over time.
There are two significant challenges here. The first is the ability of our existing health care system to integrate challenging patients into its processes. This is hard! There are reasons that these are high utilizers. My take on these results is that the support from the Coalition likely needs to extend longer to ensure patients have support longer into the integration process.
But this brings with it its own challenges. Funders have been attracted to the model because of its high return-on-investment. This type of care and integration into existing models (and, frankly, working with other health care providers to ensure they are ready to integrate these patients into their systems) is expensive work. It’s one thing to promise a multi-month intervention that changes individuals from high-utilizers to more typical health care consumers. It’s another to fund a long-term initiative to support high-utilizers to navigate a complicated health care system — potentially for years. The work may still be valuable, may still change lives, and may, over the long run, save significant money. But it’s not a silver bullet, and that’s a harder sell to funders.