Patient Engagement

High-Need, High-Cost Patients Offer Solutions for Improving Their Care and Reducing Costs

Article · February 5, 2019

By many estimates, only 5% of U.S. patients are high-need, high-cost (HNHC), yet they account for about 50% of health care spending. It has become a national priority to understand the needs of this patient cohort, identify drivers of their utilization, and implement solutions to improve their clinical outcomes while reducing their costs.

High-need, high-cost patients often have multiple chronic conditions, complex psychosocial needs, and limited ability to perform activities of daily living. Care delivery solutions, including care management, telemedicine, and home health visits, have had mixed levels of success for various outcome measures, including system-centric ones such as total cost of services and utilization of secondary care (emergency department [ED] use and inpatient hospitalization) as well as patient-centered ones such as self-assessed health status.

A possible explanation for the variable success could be that many solutions are designed primarily by health system administrators, not the patient “customers” who best understand their own needs. Little has been published about patients’ views on the care models that target their complex health care needs, which aspects of current care delivery high-need, high-cost patients find beneficial, nor how health systems can partner with patients to design and implement solutions. Better serving high-need, high-cost patients must begin with improving our understanding of their needs and perspectives.

Listening to the Voice of the Patient

To bring the voice of the patient to the forefront, qualitative researchers from Weill Cornell Medicine and University of Florida led several focus group discussions with 21 high-need, high-cost patients and 3 primary caregivers, representing an urban health care system in New York City and a second one in Gainesville, Florida. Clinical care coordinators at each site identified patients for focus groups based on the following criteria: they had at least 1 chronic medical condition and either 3 or more ED visits or 2 or more inpatient admissions during the 6 months prior to initiation of the study. (Three patients were too ill to participate, so their primary caregivers acted as proxies.)

Participants ranged in age from 23 to 80 (median age was 59) and were racially diverse (15 Black, 7 White, and 2 Hispanic). Fifteen participants were female (63%) and 9 were male. In the prior 12 months, the patients, on average, had visited their primary care doctors 6 times and the ED 16 times, and been hospitalized 5 times. Commonly reported medical conditions included arthritis, diabetes, asthma, heart disease, chronic obstructive pulmonary disease (COPD), obesity, epilepsy, hypertension, and depression.

Participants identified five solutions that they felt would help prevent overuse of the ED and other hospital services for symptoms and/or conditions that can be well-managed at primary care clinics. These are:

  • care management
  • readily available at-home physical therapy and nursing services
  • home delivery of prescription medications and easier refills
  • telemedicine
  • more after-hours clinics
What High-Need, High-Cost Patients Say About How to Reduce High Utilization of ED and Inpatient Services

  Click To Enlarge.

Patients saw immense benefit in many of these solutions (see “What High-Need, High-Cost Patients Say”). For care management in particular, patients appreciated help with appointment scheduling and reminders. Patients perceived care managers as trustworthy partners in their day-to-day health care — available to talk to and answer questions if they felt anxious. While the jury is still out on the return on investment of care management — in terms of utilization and outcomes — the patients in our focus group were convinced of its benefits.

After stays in the hospital or rehab centers, patients, especially those with mobility restrictions or transportation challenges, also appreciated home-based services such as visiting nurses or physical therapists. Private and public payer organizations already provide coverage for several types of home health care and/or personal care.

Patients also described how they sometimes are unable to pick up their prescriptions for extended periods of time and appreciated the option of having medications delivered to their residence to avoid exacerbation of their illnesses. Some also felt that for some medications, a larger supply per refill cycle would be optimal. Several pharmacy groups are piloting automatic monthly refills and home delivery of prescription medications, and these services should be more widespread and better publicized.

Patients also discussed telemedicine as a solution. Some recognized the potential benefit of telemedicine for regular appointments or non-emergent conditions. They felt that communicating with a medical provider who was personable and familiar with their symptoms could reduce the anxiety of time-sensitive, unanswered questions that often result in an ED visit. Others, however, expressed uncertainty about the use of telemedicine for conditions such as cardiovascular disease, saying that they wouldn’t take a chance with remote care in case “things go wrong” and would rather seek care in a doctor’s office or ED. While not every condition can be managed using telemedicine, patients need to be better educated about when telemedicine might be a good alternative.

Finally, patients, especially those who work 9 to 5 or whose personal caregivers are unavailable during normal business hours, felt that increasing the number of after-hours clinics at convenient locations was crucial to reducing their reliance on the ED. However, patients felt that after-hours clinics would be underutilized if transportation options were limited, reinforcing the need for convenient locations. As more health systems redesign their care delivery models, they should prioritize establishing after-hours clinics in accessible locations and educate patients about when to use these clinics instead of urgent care centers or the ED.

Almost all of these solutions are being piloted in various settings. To enhance the success of care delivery models, health care systems should consider directing more resources to some of these existing solutions that patients believe could lower utilization of secondary care for chronic disease management.

We’re in the midst of an era of patient-centered care, when patients’ needs and desired outcomes drive many of the decisions health care organizations make. It is imperative that we leverage the expertise of a group of stakeholders who know a tremendous amount about bending the health care cost curve: the high-need, high-cost patients themselves.

 

This research is supported by a grant from the Patient-Centered Outcomes Research Institute (HSD-1604-35187).

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Patient Engagement
Ghafur01_pullquote -digital health health care consumer patient experience

Engaging Patients Using Digital Technology — Learning from Other Industries

Providers can benefit patients and disrupt health care by learning from the experience of other industries.

Mission Hospital Virtual Sitter - Drawing of the Virtual Bed Zone and Rails

Reducing Inpatient Falls and Injury Rates by Integrating New Technology with Workflow Redesign

How Mission Hospital scaled a virtual sitter pilot and reduced unassisted falls by 44% and fall-related injuries by 40%.

Health Care Providers Should Incentivize Patients

Survey Snapshot: Patient Financial Incentives — There Are No Quick Fixes

The NEJM Catalyst Insights Council agrees that while financial incentives are a common strategy to engage patients in healthy behaviors, they are not necessarily effective.

Support of Family and Friends Is More Effective Than Clinician Support in Realizing Health Goals - From the Patient Engagement Insights Report: Why No Single Health Incentive Works.

Patient Engagement Survey: Why No Single Health Incentive Works

Initiatives to improve patient engagement come in a variety of forms. While insurers, employers, and health care providers are all involved in using financial incentives and penalties for engagement efforts, improvement in health outcomes has been elusive. Achieving that ultimate goal will usually require a combination of financial and social approaches.

Health Systems Attending the Nudge Units in Health Care Symposium - Penn Medicine

Key Insights on Launching a Nudge Unit within a Health Care System

Leaders are finding that making higher-value choices easier through subtle changes to choice architecture can have an outsized impact on medical decision-making.

Barriers to Providing an Oustanding Patient Experience

Buzz Survey Report: Patient Experience

An independent NEJM Catalyst report sponsored by University of Utah Health on barriers to achieving an excellent patient experience.

The Patient Engagement Capacity Framework

The Patient Engagement Capacity Model: What Factors Determine a Patient’s Ability to Engage?

Patient engagement assessments often don’t dig deep enough to identify why patients don’t participate in their own health care. We present a new model to help providers pinpoint the reasons for lack of engagement and address them more effectively.

Organizational Mindset Is the Biggest Barrier to Engaging Patients as Consumers

Survey Snapshot: The Patient-Physician Relationship Is Key

Both parties involved in a consumer-facing transaction have access to important information about the product or service — but this isn’t the case with health care.

Top Physician Pain Points Identified by Chronic Patients

Unmet Needs: Hearing the Challenges of Chronic Patients with Artificial Intelligence

With natural language processing and machine learning, researchers are identifying patient emotional and medical needs that are not being met by clinicians and patient advocacy groups.

Health Care Can Learn a Lot from Other Consumer-Facing Industries - Especially About Customer Service - Consumerization of Health Care

Patient Engagement Survey: Health Care Has a Lot to Learn from Consumer-Friendly Industries

The consumerization of health care continues to reshape the way that patients engage with providers and experience care. Most providers see this fundamental change in the health care model as a necessary response to changing patient demands, and have embraced the need to learn from other industries.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Angel Robot and a New Smart…

The Jingde Experiment’s Angel Robot illustrates how continuous, closed-loop learning symbiosis between doctor, AI, and…

Creating “One-Stop Shop” Care for Parkinson’s

Integrated Practice Units (IPUs) can revolutionize the care of specialty disease conditions, and Parkinson’s disease…

Patient-Centered Care

269 Articles

No Place Like Home: Bringing Inpatient…

Providing home-based acute care improves patient satisfaction and care quality while reducing costs.

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now