Providing care to frequent visitors who are facing homelessness, addiction and transitions from incarceration
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. The financial and non-financial impact of ineffective health care for the most complex individuals affects state and local communities everywhere. Social determinants of health have a profound impact on health outcomes, driving up health care costs. Achieving the best outcomes for the most complex individuals requires addressing the social challenges that underpin health. It also requires specialized models of care to support traditionally marginalized patients.
UnitedHealthcare recognised the challenges faced by thousands of Americans and developed a localised solution called myConnections which 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 health care 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 healthcare utilisation for high risk, high cost patients. With a focus on social determinants of health, myConnections develops deep community relationships and local expertise to bring high-quality health care 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 myConnections has identified over 25,000 homeless patients of which they are targeting the top 10%.
The myConnection’s care model involves dyadic partnerships between social workers and nurses who connect with patients and custom tailor a programme based on 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 like Social Security Income and food and housing vouchers to create long-term self-sufficiency.