myConnections: Supporting frequent visitors to emergency rooms
myConnections supports frequent visitors to hospital emergency rooms who are struggling with homelessness, addiction and transitions from incarceration. It uses an evidence-based, biopsychosocial solution that integrates healthcare and social services to transform human lives.
The ‘spend more, get less’ paradox of American medical care is well documented. Underinvestment in social services and poor coordination of supports underlie a fragmented system that fails to produce acceptable patient outcomes. Complex individuals with exceptionally high use of healthcare services are ‘real life’ examples of systemic healthcare failure.
The financial and non-financial impact of ineffective healthcare for the most complex individuals affects state and local communities everywhere. Social determinants of health have a profound impact on health outcomes, driving up healthcare costs. Achieving the best outcomes for the most complex individuals requires the social challenges that underpin health to be addressed. It also requires specialised models of care to support traditionally marginalised patients.
UnitedHealthcare recognised the challenges faced by thousands of Americans and developed a localised solution called myConnections. myConnections supports frequent visitors to hospital emergency rooms who are struggling with homelessness, addiction and transitions from incarceration using an evidence-based, biopsychosocial solution that integrates healthcare and social services to transform human lives.
The teams work within community pods to bring together housing with high-quality, evidence-based trauma-informed services to improve outcomes and decrease inefficient use of healthcare services for high risk, high cost patients. With a focus on the social determinants of health, myConnections develops deep community relationships and local expertise to bring high-quality healthcare and coordinated services to the most complex individuals.
Using internal medical claims data, myConnections has created a data-driven technique to ‘hotspot’ subgroups of the most complex patients/members across the country. Using this approach myConections is targeting the top 10% of more than 25,000 homeless patients it has identified. We use our data to identify which health systems are being most frequently used.
The myConnection’s care model involves dyadic partnerships between social workers and nurses who connect with patients and create a tailor-made programme based on the strengths and desires of the patient. The dyad works closely with the patient to navigate toward safe housing, which is provided at low or no cost for 12 to 24 months. They also navigate toward elite behavioural health services, such as dialectical behavioural therapy, medication assistant therapy, and trauma-informed primary care. The approach involves motivational interviewing and positive psychology. Moreover, the dyad also helps to navigate to social entitlements such as Social Security Income and food and housing vouchers, to create long-term self-sufficiency.
We began to analyse the results of our work in October of 2017 using pre and post interventions use of services and cost medical claims data. We found that claims costs per patient per month decreased by 52% for those that moved in on or after October of 2017. By service category, skilled nursing facilities, emergency rooms, and surgical procedure-based services of the patients served saw similar rates of decline in claims per patient per month post the October 2017 intervention.
Amy is a 31 year-old woman with a five month-old daughter who was living in a women’s shelter for several months. She was addicted to meth and heading in the wrong direction in her life.
She had experienced a number of deaths in her family and her friends in her neighbourhood also contributed to her drug use. In December 2016 Amy found out she was pregnant. She could not believe that was going to have a baby and the next day she was arrested for possession of drugs and was sentenced to jail.
Amy was given probation – a second chance – and she knew she had to change her environment and her lifestyle to give her daughter a better life. Since joining the myConnetions programme, Amy has been able to focus on her sobriety, getting stable, but most importantly, on being a mother.
She attends groups on site at the apartment complex, is engaged with behavioural health services, and meets with myConnections staff regularly for goal setting and coaching. Amy is currently studying at a community college pursuing the Behavioural Health Tech credential, with the aim of beginning a career helping others in recovery.
Amy is no longer involved with the criminal justice system. She and her baby are on the waiting list for a permanent supportive housing program in the community and she continues to work hard to accomplish her goals and be a positive role model for her baby.