Online Program

Navigating chronically co-morbid and socially complex patients: A "familiar faces" community-based model

Monday, November 2, 2015

Edward Rafalski, PhD, MPH, FACHE, Strategic Planning and Marketing, Methodist Le Bonheur Healthcare, Memphis, TN
Background: The Mid-South has the highest prevalence of chronic disease: heart disease, stroke, lung disease, cancer, diabetes and asthma.  Memphis, which is predominantly black, has a 20% poverty level and a dismal uninsured rate despite efforts to expand coverage under the Affordable Care Act and recent failure to adopt “Insure Tennessee,” a proposal to extend coverage to 200,000 uninsured Tennesseans who earn less than 138 percent of the federal poverty level (FPL) advanced by Governor Haslam in a special session of the Tennessee Legislature. 

Methods: Through a Cigna grant, a lay community health Navigator was engaged by Methodist Le Bonheur Healthcare to work with a chronically co-morbid socially complex patient population in a community that was hot-spotted using a similar technique employed in the Camden model.  Through development of trust, the lay navigator established a relationship with the individuals in the cohort and navigated patients to appropriate care settings.

Results: Within one year of implementing the model for a cohort of 90 familiar faces, we have: reduced inappropriate inpatient visits/month from 19.0 to 10.2 visits, reduced average inpatient length of stay from 4.7 to 4.5 days, reduced inappropriate emergency room visits/month from 99.4 to 73.9 and reduced overall cost/patient from $2,416 to $1,320 for a savings reduction of 45% and have successfully placed patients in a primary medical home model with improved quality outcomes.

Conclusion: We have successfully implemented a community navigation model for the chronically co-morbid socially complex patient that creates value by reducing cost and improving quality.

Learning Areas:

Administer health education strategies, interventions and programs
Assessment of individual and community needs for health education
Chronic disease management and prevention
Implementation of health education strategies, interventions and programs
Planning of health education strategies, interventions, and programs
Systems thinking models (conceptual and theoretical models), applications related to public health

Learning Objectives:
Demonstrate a successful implementation of a community-based outreach model for navigating socially complex co-morbid patients to appropriate resources. Define the terms: hot-spotting, familiar faces and rising risk in the context of population health. Evaluate the effectiveness of the "Memphis Model" in the management of chronically co-morbid and socially complex patients.

Keyword(s): Chronic Disease Management and Care, Health Care Costs

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: My academic interests include health services research, healthcare decision support, quantitative methods and health disparity reduction. I have academic appointments at the University of Memphis School of Public Health, University of Illinois School of Public Health and the University of Tennessee Health Sciences Medical School, Department of Preventive Medicine.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.