Cook County Health Program Focuses on ‘Whole Person Care’
Ensuring someone’s health wishes are met is a complex challenge. There are annual physicals and screenings, treatment for unexpected ailments and chronic conditions, remedy, follow-u.S.And tests.
But there are elements which are tougher to get entry to using traditional measures – an MRI can’t decide an affected person’s access to meals and housing. These are social determinants of health, and that they have a hefty impact – especially at the maximum susceptible patients, which include individuals who rely on Medicaid or Medicare. According to Cheryl Lulias, president and government director of Medical Home Network (MHN), which affords care for roughly a third of Cook County’s CountyCare Medicaid managed care software, about 20% of a person’s fitness is a result of medical care, whilst the alternative eighty% is an end result of social factors and other non-clinical factors like barriers to care.
“It’s important to focus on complete individual care,” Lulias says.
Patients don’t constantly assume to inform their care carriers about those forms of problems, however, and lots of are not requested.
To higher check sufferers’ wishes, MHN evolved a fitness chance evaluation to display for social hazard elements like alcohol and drug use, meals insecurity, homelessness, and intellectual fitness issues. The agency has finished 321,503 tests given that they were delivered in 2014. Assessments are finished as wanted based totally on an affected person’s threat stage, with high-risk patients receiving assessments more often than low-hazard sufferers.
Isabel Rangel, fifty-two, of Archer Heights, is an MHN affected person at Alivio Medical Center. About three years in the past, she had melancholy, tension, low shallowness, and trouble coping with her diabetes. But whilst her fitness care team dug a touch deeper, they located she additionally confronted challenges related to transportation, housing, and nutrients.
Rangel said it changed into the primary time fitness care employees requested her those styles of questions. “I felt like they knew precisely what I needed without feeling embarrassed or feeling ashamed of wanting some help,” stated Rangel, who works as a home aide.
Jennifer Rojas, a member of Rangel’s care group, said that’s the motive of the assessment: to pick out a patient’s unmet scientific, behavioral and social needs, after which deal with them.
“These non-medical limitations, consisting of transportation or get admission to healthy meals, are considered one of the largest participants to fitness inequities,” said Lulias.
Addressing these social dangers not handiest improves a patient’s universal fitness, says Lulias, it additionally reduces health care charges due to the fact there’s a direct correlation among social dangers and prices of care.
2017 examine of more than 7,700 MHN sufferers revealed that an unmarried social danger factor, including hassle securing meals, garb or housing, expanded health care costs by way of $ sixty-five in keeping with the patient, in step with month. As the number of social risk factors extended, so did the value of care, in step with the examine.
“Patients who have 4 to five social determinants and no clinical hazard have been 195% greater highly-priced inside the subsequent 365 days than sufferers without any (social hazard elements),” said Lulias, who co-authored the examine. “And the problem with that is if you just screened these sufferers on scientific desires, those sufferers could be a low hazard, however really it’s a rising threat.”
To curb that chance and improve average fitness, MHN connects patients with care coordinators and care managers who help them broaden a remedy plan, agenda appointments, achieve necessary remedy and connect them with social services, such as food pantries, among different things.
Rangel says Rojas and her care coordinator, Lizette Martinez, linked her with a local food pantry and a behavioral fitness counselor to deal with her melancholy. “I sense better about myself,” said Rangel. “I wouldn’t be right here if they weren’t there to assist me in some thing manner I wanted.”
Identifying ‘common fliers’
Addressing Rangel’s social wishes was “plenty to tackle,” stated Martinez. On top of that, Rangel wanted a number one care physician.
Not having a primary care health practitioner is not unusual among MHN sufferers, Martinez stated, but it could genuinely drive up health care charges. These sufferers are more likely to are searching for care in an emergency department, which is up to 12 instances extra steeply-priced than primary care, in step with Jim Kiamos, CEO of CountyCare.
Now, whilst an MHN affected person visits an emergency department or is admitted to certainly one of 29 Chicago hospitals, individuals of their care team receive an actual-time alert.
“We robotically do outreach to the patient throughout their medical institution stay to reassess … What added them to the hospital,” Rojas said. Teams then work to become aware of any new medical situations or social risk elements.
These real-time alerts additionally perceive so-called frequent fliers – people who use the emergency room as they would a primary care doctor, says Kiamos. “(The alert) lets in us … To interact with a member and pull them again into the number one care stage” where the remedy is extra powerful, he said.
Care teams also are alerted while patients visit any of the network’s extra than 200 clinics to acquire primary or uniqueness care. Knowing how a patient accesses care allows care coordinators and executives to reduce boundaries to care whilst educating patients on appropriate use and a way to manipulate their personal care, says Lulias.