Social Coordination of Healthcare

The whole costs less than the sum of the parts.

According to data collected till 2009 for the 100,000 Homes Campaign, about half of our nation's hundreds of thousands of homeless people have either a medical, mental, or substance abuse problem, and one quarter have all three. Unfortunately, their healthcare provider of choice--emergency departments--is the most expensive one.

Providing regular housing to homeless people on its own decreases their per-capita health care cost from $28,436 to $6,056, according to Boston's Health Care for the Homeless program. However, just as five percent of our country's population uses fifty percent of our healthcare resources, there is a similar stratification of need among the homeless. Patients with a cluster of chronic needs, or a debilitating condition that can be improved with a few weeks or months of treatment can be channeled away from acute care, if given assistance in navigating the healthcare system. Coordination of care by nurses and social workers connects them with primary care and this team combats the mental health, substance abuse, and social issues. Developing a first-name relationship and giving tailored, ongoing support, makes the difference in these successful programs.

Communities from Portland to Philadelphia are identifying and partnering with these homeless patients. In one success story, Portland's Recuperative Care Program has been taking high-need patients from the ER into a 30-day medical home and assigning them care coordinators, and has reported rates of 74% medical recovery and 61% discharge to stable housing. Oregon Health and Science University hospital leaders report that since 2005, they paid $500,000 to the program and thereby saved $3.5 million in costs, by reduced retreatment visits in the ER. At the heart of these results are care coordinators who know the patients personally, and help them execute primary-care centered, long-term plans.

System-level healthcare integration is not only important for the homeless. Disjointed, high-cost, acute care for the homeless is reminiscent of our broader system. Truthfully, few of us find a medical home. Perhaps these programs are the first stones to be thrown in a Copernican Revolution which recasts the patient at the center of our medical system. Patient health at the bottom line is the organizing principle, and primary care is the organizer. Without them, specialty interventions become so many soldiers without a general or a plan.

Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. Institute for Healthcare Improvement white paper.