How to Address High Utilization in Health Care

Crossposted from Hospitals & Health Networks online magazine on January 26, 2017

In the United States, more than 50 percent of health care costs are accrued by 5 percent of patients. It is not surprising, then, that health leaders’ focus on the Triple Aim — which calls for simultaneously reducing costs, raising quality and improving population health — includes high utilization.

There is substantial opportunity for innovation. For example, federal, state and private sector entities are allocating resources to new, high-utilizer initiatives such as health homes (Section 2703 of the Affordable Care Act), provisions of Section 1115 Medicaid demonstration waivers and components of accountable care organizations. In most cases, the conditions that underlie excessive utilization can be prevented or substantially mitigated.

Our two organizations recently published pieces describing fresh approaches to high utilization in community prevention and care management. On the surface, these two approaches seem disparate or even contradictory: One focuses on pulling the lens back so the clinical encounter is seen in a broader, community context; the other zooms in to look at relationships within health systems. Yet, these two perspectives are complementary and, in fact, are core components of a necessary, comprehensive approach to high utilization.

Complex interventions

High-utilizing populations need coordinated, responsive care. They need access to a range of behavioral health and social services. And they need an environment that promotes and supports the maintenance of health.

Caring for populations with complex health and social needs requires commensurately complex interventions. For example, a number of health systems are adopting innovative approaches that combine intensive-care coordination with supportive housing for high-utilizing populations who are facing housing insecurity, chronic disease, substance use disorders, and mental health conditions, and who are bouncing from the streets to emergency departments to inpatient stays to jail — frequently interacting with first responders (law enforcement and emergency medical services) and clinical providers.

A comprehensive approach to high utilization

Providing integrated care may help manage an individual’s conditions, but the gains for population health will be marginal without addressing underlying issues such as access to stable, safe, affordable housing.

Initiatives in multiple states have shown that supportive housing for high utilizers can have dramatic effects but that the issue cannot be dealt with solely through strategies implemented within clinical institutions. Individual referrals to social services and community-based organizations are important; it is also critical, however, to develop strategic relationships to support an integrated response to housing insecurity. It is also essential to support advocacy and policy changes that ensure resources (such as affordable and safe housing units) are available for all community residents.

The following are important reasons to plan and implement a comprehensive approach to high utilization:

Comprehensive approaches work. Past efforts to address problems such as tobacco and lead exposure, as well as contemporary efforts to address issues such as obesity and asthma, have relied on comprehensive approaches that focus on individual needs and behavioral changes as well as on transforming community environments and social norms. For example, Cincinnati Children’s Hospital identified dramatic disparities by neighborhood in admissions rates for asthma. Nurse practitioners in a home visiting program (focused in part on medication adherence and environmental mitigation) identified consistent pest problems and water damage in neighborhoods with the highest admissions rates.

Through a partnership with the Legal Aid Society of Greater Cincinnati and the local health department, Cincinnati Children’s discovered that a significant number of recurrent patients lived in buildings owned by one landlord who was not complying with codes and regulations. After Cincinnati Children’s and its partners pressured the landlord, the property manager, and Fannie Mae, the landlord made major improvements, including new roofs and ceilings and updated air conditioning and ventilation systems. Cincinnati Children’s documented health improvements among the affected populations, including reduced readmissions among Medicaid patients.

Current frameworks and concepts — such as the Centers for Disease Control and Prevention’s Three Buckets of Prevention and the Robert Wood Johnson Foundation’s Culture of Health, as well as initiatives such as the Accountable Communities for Health pilots in several states — reflect an emphasis on comprehensive action. Health care analysts and forecasters are increasingly pointing to the potential impact of collective investment in comprehensive strategies.

Successful initiatives rest on cross-cutting elements. Launching a successful care management model depends on:

  • Committed leaders.
  • Integrated data systems that collect and share clinical information on social factors.
  • Staff with strong interpersonal skills to engage patients and to navigate clinical and community-based systems.
  • The financial flexibility to invest in comprehensive approaches to health and well-being.

Those same elements are necessary for community prevention efforts to support optimal health and well-being.

Comprehensive approaches enhance both short- and long-term prevention. Strong relationships between clinical staff and patients, a range of readily available services and resources, and health-promoting community environments provide the basis for long-term health and wellness. Addressing housing, food insecurity, transportation and economic opportunity for high utilizers can also prevent utilization rising among high-risk individuals. It also helps sustain the health of those with no medical issues as well as of those who are managing chronic conditions.

Return on investment

Health care is rapidly shifting away from fee-for-service reimbursement to incentivizing value-based care. Simultaneously, there is more evidence and recognition of the extent to which social factors shape health. Comprehensive strategy development for high utilizers aligns with both of those developments.

It is essential for health care leaders to embark on collaborative efforts to improve community environments as a complement to improved, coordinated service delivery. As health care leaders consider options for improving quality and reducing costs, they have an opportunity to implement comprehensive models that join effective care coordination with high-quality, communitywide prevention. Investing in both can result in short- and long-term returns to health care and broadly transform a population’s health.

Jeremy Cantor, M.P.H., is a senior consultant at JSI Research & Training Institute Inc. in San Francisco. Larissa J. Estes, Dr.P.H., is a program manager at Prevention Institute in Oakland, CA.

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