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

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.