Patient Engagement

Social Interventions Can Lower Costs and Improve Outcomes

Article · March 7, 2017

It was a hot and humid day in Houston — the oppressive sort that makes one contemplate retreating to air conditioning immediately after stepping outside. Our patients did not have that luxury.

Our group of medical professionals was the Street Outreach team for Healthcare for the Homeless–Houston (HHH), a nonprofit that provides health care, social, dental, and psychiatric services through three private clinics. With a mix of volunteers and individuals employed through HHH, our team of medical students, a doctor, a nurse practitioner, and a case manager seek to meet Houston’s homeless population where they live, visiting known communities of homeless individuals weekly to connect them to HHH services, placing them on the housing list, and helping them get the identification necessary to access services.

Sometimes, all that some patients need is a hygiene kit, a bottle of water, and some kind words. On this blistering June day, that was not the case when an overweight, middle-aged man tentatively approached. He spoke in a mumble, barely audible. His face was expressionless, but his fearful eyes darted furtively around the gazebo where the community was taking refuge from the relentless sun. Though he admitted to hearing voices, only someone trained to recognize his wandering gaze and quivering lips would recognize the traces of psychosis. His beard bore traces of grooming from a recent hospitalization for suicidal ideation, after which his diabetes medications had been stolen. Collecting his personal information to make him an appointment for the next day, I noticed that it was his birthday, wished him a happy birthday, and gave him an extra granola bar. He started crying. This man, hardened by life on the street, was brought to tears by common decency. It had been years since anyone had wished him a happy birthday.

He was perversely fortunate to be actively hallucinating, so he jumped to the top of the housing list. He was placed in emergency housing and started a relationship with a case manager. He was able to see a physician the next day, who re-prescribed his chronic diabetes and schizophrenia medications. He was offered access to a trained therapist: the elusive biopsychosocial intervention.

Most of our patients are not so fortunate. The previous week, we met a jolly woman, bronzed by constant exposure to the harsh Houston sun, who asked us for help with her lung cancer. She told us that she had had surgery several months before, but was unable to make it to her follow-up appointments. When asked about her surgery, she described how her face and arms had puffed up and reddened like a strawberry-hued marshmallow. Sure enough, when we remotely accessed her record, we learned she had been treated for superior vena cava syndrome due to an underlying squamous cell carcinoma, but she had been “lost to follow-up” prior to initiating chemotherapy. Her doctors had done everything they had been trained to do: they performed a difficult, life-saving operation and provided her with appropriate follow-up. But she couldn’t make it to her appointment, and unfortunately, she lost precious months as her disease progressed. Disheartening stories such as hers are what led Dr. Buck, the Founder of HHH, to start Houston’s Patient Care Intervention Center (PCIC), which improves health care quality and costs for under-resourced populations through data integration (social and medical) and care coordination.

The effects of social factors on health outcomes have been well documented. Individuals from lower socioeconomic classes experience higher rates of asthma mortality, tuberculosis exposure, lung cancer, lead poisoning, obesity, life stress, and, most tellingly, all-cause mortality. Social factors are particularly acute for homeless individuals, who have a 3 to 4 fold increase in mortality compared to the general population. Housing First programs, which immediately place homeless individuals in housing, have been shown to improve overall health, decrease alcohol abuse, and lower social costs. PCIC has applied this concept to so-called superutilizers. We wanted to see if we could have similar success by addressing the social needs of those with complex medical issues, whether homeless or domiciled.

By combining data from multiple hospital systems, PCIC’s data analysts identified 39 patients in the community, who, in the previous year, had either visited the emergency room at least 10 times or been admitted at least four times. After enrollment in PCIC’s program, these patients participated in weekly meetings with care coordinators, received social assistance, and were chaperoned to primary care appointments, among other interventions. After 6 months in the program, we found that these measures decreased health care utilization, lowered total health care costs, and improved these patients’ quality of life. More specifically, the total health care costs of the 39 patients dropped from $2.3 million in the 6 months preceding the intervention to $1 million in the 6 months during the intervention. Additionally, before being enrolled in the program, the 39 patients had a combined 360 ER visits and admissions compared to 131 visits after program enrollment. Perhaps most tellingly, the patients’ self-reported functioning on the Daily Living Activities functional questionnaire (DLA-20) rose from an average of 43 to 51.

Analysis of health care utilization cost and patient functioning in PCIC social interventions_new

  Click To Enlarge.

These promising initial data may represent a possible solution to social and health care problems plaguing many of our patients today, but there remains much work to be done. Longitudinal data is still being collected to determine if cost savings and life improvement continues in these patients after graduating from the program. More resources are required to determine if the data can be replicated in larger sample sizes with true control groups. Rather than focusing solely on economic impact, it may also be helpful to measure the impact of these interventions compared to other medications and social resources in a broadly applicable measure such as Quality Adjusted Life Years. Moreover, current systems lack the necessary infrastructure to effectively track health and social outcomes to determine the effectiveness of these interventions.

It will always be necessary to explore the frontiers of medical knowledge — to strive for newer, more effective treatment. One way that health care providers can better serve our under-resourced patients with complex medical and social needs now, however, is by helping them access treatments and social interventions we already know to be effective. This can only be accomplished by dedicating more research and public funds toward innovative social interventions.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

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

Learn More »

More From Patient Engagement
Bilazarian01_pullquote patient engagement both sides of the bed

Patient Engagement from Both Sides of the Bed

When patients and families are included in medical rounds as valued members of the team, the quality of care improves.

Ten Guiding Principles for Patient-Centered Care as Described by Mountain States Health Alliance to consider with patient-centered outcomes research (PCOR)

Complementary Approaches to Patient Engagement in Patient-Centered Outcomes Research

It’s important for providers to understand and apply the key principles foundational to patient-centered outcomes research efforts.

Selected Advantages of Improved Patient Electronic Access to Health Data

Patient-Led Data Sharing — A New Paradigm for Electronic Health Data

The pieces are in place for a truly disruptive shift in how patients can access and use their own clinical data to improve their health.

Collapse of Two Online Health Communities as Result of Removal of Users Starting from Superusers

Online “Superusers” as Allies of the Health Care Workforce

Three proposed steps for integrating peer-driven online health communities with traditional services to improve health outcomes for people with chronic conditions.

The PEACE Project - Patient Experience for Acute Care Elders at Sarasota Memorial Hospital

The PEACE Project

Improving the acute care experience for our eldest patients.

Rabson01_pullquote barriers to patient engagement in primary care practices

What Does It Take to Increase Patient Engagement in Primary Care Settings?

Massachusetts primary care practices are beginning to invest in programs to increase patient engagement, but these strategies can be challenging to implement and remain underutilized and undervalued.

Many Barriers to Engaging Patients in Treatment for Obesity

Survey Snapshot: Approaches to Address Clinician and Societal Roles in Obesity

The obesity problem is getting larger and larger. Some solutions lie beyond the traditional medical setting.

Esch01_pullquote patient activation

OpenNotes, Patient Narratives, and Their Transformative Effects on Patient-Centered Care

The development of standardized tools and techniques are enhancing the ability of providers to interact with patients, but true patient engagement requires a common understanding of its theoretical foundation and an open mind for including patients’ needs and beliefs — in their language — as part of each encounter.

Patients and PCPs Hold Primary Responsibility for Addressing Obesity

Patient Engagement Survey: The Failure of Obesity Efforts and the Collective Nature of Solutions

Patients hold responsibility for their actions, but providers’ approaches to address obesity often fall short as well.

Items from the Shared Decision-Making Process Survey for Elective Surgical Procedures - patient decision aids - decision quality - informed consent

Shared Decision-Making: Staying Focused on the Ultimate Goal

Despite growing acceptance and enthusiasm for patient involvement in their health care decisions, clinicians, at times, lose focus on the ultimate goal of shared decision-making: better health decisions from the informed patient’s perspective.

Connect

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

Learn More »

Topics

Patient Incentives

68 Articles

Online “Superusers” as Allies of the…

Three proposed steps for integrating peer-driven online health communities with traditional services to improve health…

Patient-Centered Care

245 Articles

Engaging Stakeholders to Produce Sustainable Change…

How an initiative designed to improve patient outcomes and satisfaction while containing costs led to…

Patients As Customers

123 Articles

Patient Engagement from Both Sides of…

When patients and families are included in medical rounds as valued members of the team,…

Insights Council

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

Apply Now