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Keeping high risk patients healthy at home

Staying on top of multiple chronic illnesses such as diabetes and heart failure can be a challenge for even the most well-resourced patient – imagine doing so while battling homelessness and schizophrenia. The result is often frequent trips to the emergency department and the hospital. This is not an uncommon scenario for patients who have co-occurring chronic conditions, mental illness, and social stressors, making them high risk for re-current hospitalizations. And, not surprisingly, many healthcare systems have started implementing programs to address the needs of these patients.

Intensive outpatient programs attempt to identify and treat high-risk patients before they need to visit a hospital. These programs typically offer care coordination, case management, social services, and around-the-clock access to clinicians. The thinking goes that spending money up front on an array of resources may prevent an even more expensive hospitalization from occurring, saving costs to the health system while keeping patients healthy at home.

Although a promising and simple idea, intensive outpatient programs have not consistently shown to improve health care outcomes or to improve costs. Experts think that failing to engage high risk patients in these programs may account for their limited success so far. Making resources available is a first step, but getting medically and socially complex patients to use them presents a greater challenge.

We reached out to a diverse group of intensive outpatient programs in Northern California to learn how front-line providers describe patient engagement in terms of their complex patient population. The participants’ vast experience illuminated how engagement of high-risk patients in intensive outpatient programs is unlike that of any other group of patients. By sitting down with nurses, physicians, care coordinators, and other providers, we sought to understand what a truly engaged patient looks like in this high-risk population.

The findings of our study are summarized in the Engagement Through CARInG Framework. The CARInG Framework categorizes engagement of high risk patients into three domains: Communications and actions to improve health; Relationships built on trust in IOCP staff; and Insight and goal-setting ability.

Intensive outpatient programs have not consistently shown to improve health care outcomes or to improve costs.

First, engaged patients communicate with providers and take actions to improve their health. Calling doctors, showing up to appointments, and picking up prescriptions are all signs of an engaged patient. Even opening the door for a visiting nurse can be a sign of engagement, and not a given among a patient population that frequently battles mental illness and immense social stressors.

Second, engagement requires relationships built on trust. As one provider explained to us: “Patients were skeptical and hesitant: ‘This is too good to be true. How are you going to do this or that?’ We just took it one day at a time and showed them, ‘We want to see you healthier and living a happy life.’”

Finally, engaged patients develop insight and the ability to set goals for their health. A patient engaged in an intensive outpatient program defines their own health goals and understands how take steps to achieve them. As one provider said: “It involves not telling the patient what they need to do but […] having the patient try to think out their own problem and their own resolution.”

The Engagement Through CARInG Framework outlines the skills, attitudes, and behaviors that comprise engagement for high-risk patients. It also demonstrates that engagement for high-risk patients contains subtlety that might not be obvious to providers unfamiliar with this population. For instance, participants in our study told us how engagement can vary amongst the three domains described above. One provider described how highly insightful patients (the third domain) can still be engaged in their care even if they struggle to take important actions to improve health (the first domain): “[Patients] are still engaged when they respond to the person they are working with and say, ‘I can’t do this right now.’ When they can name that this is not a good time for them, that really shows engagement and progress.”

There is a critical demand for effective interventions for patients with medical, social, and behavior complexity. The CARInG Framework collects and organizes the wisdom and experience of providers and care coordinators who have worked with hundreds of high risk patients. Improving engagement will undoubtedly be needed to reach the full potential of intensive outpatient programs for high-risk patients, and the CARInG framework can be used as a launching pad for interventions to improve this promising approach.

Featured image credit: Giving by Tom Parsons. Public domain via Unsplash

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