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Integrated Model of Care for the Frequent User Population: Impact on Patient Health & Wellness and Health System Transformation

Dr Anne Snowdon is Academic Chair and Professor, World Health Innovation Network (WIN), Odette Business School, University of Windsor, Ontario, Canada.
Carol Kolga, Abdul Kadir Hussein and Sarah Padfield are also part of the WIN team.

Authors share, Intentional or unintentional – frequent use of medical and healthcare services have led the way towards the design of an integrated approach in healthcare management

Health systems worldwide are challenged by the increasing demand for services while operating within limited fiscal resources to meet growing patient demand. There is an increasing recognition that small segments of the population are accessing health services very frequently due to multi-co morbidities and very complex health needs.  In one Canadian province, it has been documented that just 5% of the 13 million citizens consume and account for 67% of health system service resources (Wodchis, 2013). This population is an important priority patient group in the region, known as the ’frequent user’.  The majority of these individuals have multiple co-morbidities and are confronted with navigating numerous, complex health services across a number of different programs, medical specialties and locations which are often isolated and disconnected from each other and focused on a single disease management approach. The frequent user population has expressed many challenges and significant dissatisfaction with accessing current health services that are neither integrated nor connected in a meaningful way.

This lack of integration and coordination leads to gaps in care, frequent use of emergency department services, and hospitalizations when their health deteriorates. 1% of the province’s ‘frequent user’ population consumes 34%, and the top 5% consume 67% of health system expenditures in the provincial health system. There is an impressive opportunity to implement an innovation strategy to re-design health services to more adequately meet the needs of these complex patients, and in doing so, reduce health system costs through a more coordinated and integrated model of care, focused on health and wellness that enhances quality of life.

A collaboration team for research is currently underway to design and implement an integrated health services strategy for patients identified as ‘frequent users’ across one provincial region.  The research team is examining the impact of this integrated model of care that leverages innovative technology to identify the frequent users in real time as they access health services.  A case management solution designed by the clinical team is implemented to engage patients and their families as partners in managing their own care, and focus on meeting the health goals identified by the patient and family rather than disease management goals determined by clinicians.  Results of the pilot phase of the research demonstrated that patients’ utilization of services decreased dramatically over a six-month period after the integrated model of health services was implemented.  Outcomes measured included the patient’s self-report of perceived wellness, satisfaction with the new model, ease of accessing primary care services and health services utilization (emergency visits, hospitalizations, length of stay).

Preliminary Findings Over a 6-month Period:

Frequent Users require integrated care led by primary care teams that engage specialists only when required, self-identified health goals focused on quality of life and maintaining their independence in the community, reported high levels of perceived wellness and readily engaged in self-management, with the support of their primary care team and a case manager as well. Clinicians reported working collaboratively to achieve integrated services focused on patient health and wellness across primary and specialist care. Health service utilization data for this population demonstrated 40% reduction in hospital days, reduced emergency department visits, and reduced length of hospital stay.

Both – the collaborative approach to integrated care and building an innovative eco-system strategy into the region to influence system change – are key conditions affiliated with the success of the integrated model of care in this pilot phase of the study. Phase II of the study continues with approximately 300 ‘frequent users’ being followed for 12 months to determine the impact of this integrated approach to care over time.

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