High-intensity primary care models can reduce healthcare utilization, but robust multidisciplinary approaches are necessary to improve risk stratification, social determinants of health, and behavioral health for high-needs, high-cost patient populations.

The total cost associated with healthcare in the United States continues to climb, with healthcare expenditures now representing 18.3% of the gross domestic product. Healthcare spending remains highly concentrated, with a small proportion of patients accounting for more than half of total healthcare costs; this group of patients have been referred to as high-need, high-cost patients (HNHC). With the evolving landscape for financial reimbursement in healthcare shifting from traditional fee-for-service to value-based contracts, finding ways to manage both costs and quality of health for HNHC patients is imperative.

In 2013, our academic learning health system created the Care Plus program in collaboration with our local Managed Care Medicaid and our county’s behavioral health management entity. The Care Plus program provides intensive primary care, behavioral health services, and care coordination for HNHC patients (more than 3 hospitalizations or Emergency Department visits in the past year) from our safety-net Internal Medicine clinics. The goal of this program is to provide more frequent, longer duration, in-clinic and/or home visits involving multidisciplinary team members to address the numerous structural and social determinants of health faced by our HNHC patient population.

Growing attention has been placed on the effectiveness for programs targeting HNHC patient populations. More recent studies have evaluated changes in healthcare utilization over the first 30 days to 1 year of program enrollment. Given the long-standing duration of the Care Plus program, we wanted to better understand the characteristics of patients who enrolled versus declined program participation as well as the longitudinal impact on acute healthcare utilization.

Major Findings:

• Patients who chose to enroll in the Care Plus program were more likely to be experiencing homelessness, have a mental health diagnosis, and lack health insurance than those who declined enrollment.
• Emergency Department and inpatient utilization decreased over time for patients who enrolled in Care Plus, but this wasn’t significantly different than the decline in acute care use for patients who declined program enrollment.
• For patients enrolled in Care Plus for more than 2 years, we found a sustained decrease in Emergency Department utilization.

Why is this important?

• HNHC patients who chose to enroll in our Care Plus program were incredibly medically and socially complex, with characteristics that can make measuring program engagement and impact challenging. Having a better understanding of HNHC patient characteristics emphasizes the need for critical wraparound services within these programs, such as embedded behavioral health and increased social support.
• High-intensity primary care programs like Care Plus might be able to reduce unnecessary or frequent Emergency Department visits, but patients with complex medical and psychosocial illness often require hospitalization for disease stabilization.

Future considerations:

Programs targeting HNHC patients require an individualized, multidisciplinary approach. Additional considerations for future studies include:

• Identifying rising-risk of medically complex patients before hospital-level care is inevitable
• Distinguishing the impact of other community and system-level interventions targeting the same HNHC patient population
• Understanding the role of trust, relationship-building, and navigation within healthcare systems for HNHC patients

Read Our Article in the Journal of Public Health Management and Practice:

• Evaluation of “Care Plus,” A Multidisciplinary Program to Improve Population Health for Patients With High Utilization

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Jessica Valente, MD, MPH, serves as Medical Director for Care Plus and Associate Program Director for Ambulatory Education for the Internal Medicine Residency at Wake Forest School of Medicine. She is interested in improving patient and trainee experience in primary care, with a special focus on patients from traditionally disadvantaged backgrounds.

Kirsten B. Feiereisel, MD, FACP, is an Associate Professor at Atrium Health Wake Forest Baptist.  She is Section Chief of General Internal Medicine and Medical Director for Ambulatory Quality.  She is active clinically in the care of vulnerable populations and leads design and implementation of processes to improve care, quality, and outcomes.