Health care intervention: Treating high-need, high-cost patients

In crisis and with nowhere else to turn, thousands of patients with complex needs -- serious mental and physical health problems and substance use disorders -- every year flock to emergency rooms in Harris County, Texas and across the country. Referred to as "high-need, high-cost," these patients have limited ability to take care of themselves, making it challenging for doctors to find effective treatments.

Their health problems are mostly left unresolved, and they consistently return to the ERs costing the health care system billions every year. The ERs are not designed to address chronic medical or acute social problems such as homelessness, hunger, and job loss.

New research suggests a nontraditional approach to these patients can significantly improve their daily functioning and health outcomes.

Complicating matters, patients with a number of different diagnoses typically visit multiple medical and social service agencies -- hospital systems, health clinics, food pantries, shelters -- with no collective record available to each organization. This can lead to both gaps and overlapping services, resulting in higher costs and insufficient care.

"The diagnostic-based approach -- telling patients what's wrong and here's how to fix it before sending them on their way -- coupled with a lack of information about where they've been, has worked spectacularly badly for underserved populations who already have reason not to trust us," said Dr. David Buck, associate dean for community health at the University of Houston College of Medicine. "We need to find a better way to not only lower health care costs, but more importantly, improve their quality of life."

In a study published in the journal Population Health Management, Buck and his research team report a novel intervention that integrates a psychological, values-based approach with coordinated care management significantly helped improve daily functioning -- including money management, personal hygiene, social connectivity and relationships -- for this vulnerable group of patients.

This "values-based" approach to care was applied to 18 high-need, high-cost patients at the Patient Care Intervention Center in Houston, a nonprofit organization founded by Buck. Over the course of six months, care coordinators worked with the patients to identify their values and associated goals as a way to start meaningful discussions and ultimately engage them in appropriate care.

Buck calls it a way of "centering" providers on who or what is most important to the patient through a cognitive behavioral therapy informed approach.

"Instead of focusing on their problems, we focus on their values and goals. Instead of the push and pull of doctors telling patients not to do something for the sake of their health, we look at who and what is most important to the client," said Buck. "It's trust building and a way to reach the root of the problem."

The nonprofit also integrates millions of service utilization records from medical and social service agencies through its comprehensive health record system, called the Unified Care Continuum Platform. By linking data from patient visits, the researchers wrote, "communication gaps between agencies (that work independently) are bridged to provide a complete view of utilization and needs, as well as identify common clients and service gaps in the community. This helps to overcome systemic barriers to health that might exist and reduce duplication of services."

Buck recalls a patient with HIV and bipolar disorder who showed up at emergency rooms every few days. The patient racked up more than $1 million in bills. "No one was successful in engaging him. He hated the ER's, but he was in crisis," said Buck, who discovered that the patient's dog was his main motivation. The patient left his dog tied up and alone for days whenever he went to the hospital.

"Instead of just demanding he get on his meds, we discussed what was not working for him. Instead of getting in the medical zone, we would go back to the dog. He didn't like leaving his best friend behind. We would ask what was getting in the way of his value to be good to his dog. He identified his need to get primary care for his chronic illnesses rather than acute crisis care. This approach gives people the power to decide how they need to behave instead of being told," Buck said.

The patient now regularly visits a primary care clinic, avoiding the emergency room. Buck said if the intervention could positively impact even the most challenging patients, it has implications for improving health care for everyone.