Hospitalized Frequent Flyers: The Solution for North Texas

One of the main reasons for rising hospital costs and decreasing health outcomes is the frequent fliers in the hospital. This person is often in and out of the hospital but cannot remain healthy for a variety of reasons. The person is usually poor, uninsured, or elderly, and faces numerous barriers to staying healthy.

Housing, education, transportation, access to healthy food, mental health problems, or other social health factors prevent that person from staying healthy after discharge. While hospitals have social workers who ask about needs outside of the immediate medical issue, it can be difficult to ensure patients access the services after their hospitalization or doctor’s visit.

The patient can go to a panel or number with a contact to request a housing or transportation voucher, but follow-up is even more critical. Without addressing these issues, the patient may miss their medication, miss follow-up appointments, or lack access to the healthy foods they need to stay healthy.

The Parkland Center for Clinical Innovation and its partners are committed to addressing this ongoing problem; It required years of theoretical planning and implementation. Here’s what it did.

PCCI leveraged a Centers for Medicare and Medicaid Services program called Accountable Health Communities, which was created to address social determinants of health and reduce hospital utilization. These communities are made up of health systems and community-based organizations. In North Texas, PCCI helped bring together Parkland Health, Baylor Scott & White Health, Children’s Health, Methodist Health System and Metrocare Services, which partnered with more than 100 community-based organizations and the Texas Health and Human Services Commission to provide a full service for Dallas residents living in ZIP codes with lower social determinants of health.

The results of this five-year initiative were recently published in the New England Journal of Medicine. During that time, the partnership studied 12,548 high-risk Medicare and Medicaid individuals and identified 19,000 distinct needs, with 61 percent of individuals having more than one need. The organizations worked together to meet this need, distributing £200,000 of food and $540,000 in utility and rental assistance.

While patients benefited from the resources, part of the benefit was knowing someone was checking in on them. “A lot of the patients said that nobody ever called them after they left the hospital and that’s really nice,” says Dr. Jacqueline Naeem, Senior Medical Director at PCCI.

But this initiative is not just a charity effort. The theory is that the resources devoted to addressing these social determinants keep people healthy and out of the hospital, where they often deplete health care resources and increase overall health care spending. PCCI used an algorithm to identify those most at risk, put them in touch with community-based organizations, and followed up regularly after release. At the same time, community health workers from PCCI and participating health systems would screen individuals to ensure their needs are being met.

The initiative confirmed the theory. The program resulted in savings compared to not addressing these needs and paying for the health care costs. Additionally, individuals who received follow-up visits to the emergency department less than a comparable control group and used the hospital less during navigation and in the 12 months following the interaction.

The group was also more likely to seek and keep appointments at outpatient clinics than the control group. These visits help keep patients’ recovery on track and away from the hospital. Overall, the initiative resulted in a 1.3 to 1 return on investment, with gross savings of over $1.25 million.

More research is needed, but North Texas and PCCI published the first study on the CMS initiative with positive results. The next task, Miff says, is perfecting the processes without compromising clinical care and being able to teach other communities how this type of collaboration works for them. “I’m encouraged by how you’re taking this process to sustainability or to other markets,” says Miff. “Yes, it works, but you have to adapt it, internalize it and figure out what it takes to go to other markets.”


Will Maddox

Will is the senior editor for D Managing Director Magazine and publisher of D CEO Healthcare. He has written about healthcare…