CommunityConnect

By Hannah Lambalot | Categories: | Comments Off on CommunityConnect

Contra Costa Regional Medical Center’s (CCRMC) top 5% of users represent 49% of total costs, and the top 15% of users represent 79% of costs. Through a review of high need patients, it was revealed that a large portion of these high costs were associated with patients accessing medical services due to underlying social needs.

CommunityConnect was designed to target interventions for high-need patients with the aim to provide upstream care and services. The program utilizes predictive model analytics, that incorporates data points from across county, to proactively identify patients that are likely to use the emergency room or be admitted to the hospital for an avoidable reason in the future, such as to meet their urgent social needs. Patients who are enrolled into the program are provided one year of case management to coordinate medical services and provide community and government resources that can improve patient well-being and health. CommunityConnect receives funding of $40 million annually through the California Medicaid 1115 waiver Whole Person Care.

Patients are identified and enrolled int the program based upon data gathered through a comprehensive set of sources: from Medicaid managed care plans, behavioral health, the coordinated entry housing program, EMS and the county detention facility. These data points are combined to create patient-level risk factors. As the program identifies enrollment based on a predictive model, a number of patients are identified for enrollment not based on their prior health utilization (based on Medicaid claims data, apart from CCRMC). Leveraging data through a holistic patient record allows for identification of county residents that may not have otherwise ever been referred into services through traditional means.

Upon patient enrollment, case managers conduct a comprehensive social needs assessment with the patients to identify areas in which the program can help. This covers areas such as: medical, behavioral health, safety, housing, food security, transportation, finances, legal, and support system. Depending on patient acuity, case management services are either provided in-person or telephonically by multi-disciplinary staff that includes public health nurses, social workers, substance use counselors, homeless services specialists, mental health clinicians, and community health workers.

Once the CommunityConnect  case managers assess a patient’s unmet social needs, they help enrollees create a patient- centered care plan, access resources, and work in partnership with the patient and other care team members to implement the plan, with the shared goal of improving the patient’s health. In addition to a providing linkages to community resources through a comprehensive social needs online resource directory, the program provides direct benefits to patients aimed at addressing unmet social needs. CommunityConnect patients have access to a transitional housing fund that can assist with security deposit or moving costs; a free cell phone in order to engage in services and link with resources; non-medical transportation in order to obtain identification documents; Free legal assistance from two full-time lawyers at the local legal aid; and social service workers to help apply and renew public benefits including Medicaid, SNAP, and TANF.

Since June 2017, the program has connected more than 17,000 people to critical health and social services. The first year (2017) resulted in a 3% reduction in ED visits and an 12% reduction in inpatient admissions compared  to 2019 results that improved to show a 20% reduction in ED visits and 18% reduction in inpatient admissions. Other measures are in process of being analyzed, including primary care visits, behavioral health visits, access to public benefits, and other biometric health indicators. Success measures show that 37% of patients that lapse Medicaid are able to be restored within 90 days due to case management services, and 34% of patients have had a successful outcome with a social-related goal.