Published On: September 13 2017 in National Center for Complex Health and Social Needs. This is an interview with Kallol Mahata. Read the article here.
At the heart of complex care is identification: Where and how do we find the most vulnerable patients? When our team started studying individuals in Houston who tend to overuse emergency department and inpatient visits, we realized our community was siloed in its approaches.
Health systems and hospitals were telling us these individuals were only visiting their systems, but we suspected this just wasn’t the case. Testing our theory, we linked data from institutions across organizations – not just medical services data, but social services as well. Data on EMS services in Houston proved to be our missing link:our analysis confirmed high utilizers were visiting multiple health systems. We learned more about their health needs and the fragmentation of their care by overlapping data from multiple providers and agencies, a process that helped us build a Master Client Index – a database connecting these individuals across buckets of datasets.
We have also developed what we call a Unified Care Continuum Portal (UCCP), an integrated platform to share care plans among a person’s providers, which aids in bridging the gap between the social and medical agencies providing a patient’s care. The best way to describe UCCP is to share how it impacted a client – someone I’ll never forget working with.
He matched in our homeless and medical datasets: homeless for three years, racking up numerous ER visits at multiple institutions, despite being on disability and Medicaid. His services just weren’t being coordinated and we felt a value based care plan could really improve his situation. So, using our UCCP model, we worked to find out what was important and motivating to him. It was his dog.
We learned that the man’s dog was a large part of why his social needs in particular were not being met. What could we do? We aligned his care around his dog: he had never been able to get pet-friendly housing, so our team worked to have his dog designated as a service animal. This relatively simple intervention had a cascading effect – it helped him not just get housing, but finally made it feasible for him to attend primary care appointments and start taking medication. His contact with the ER went down dramatically.
Our work at PCIC helped this man turn his life around. Being a part of an organization that’s changing lives is why I love my job. Here in the U.S., healthcare has been delivered in a certain way for a long time – we’re trying to change its direction, to better accommodate the realities of individuals with complex needs. We’re trying to change course and focus on “health care” rather than “sick care.” And we’re making a real impact.