Funder: Kaiser Permanente Community Benefit

March 2017 | Presentation


As health care increasingly focuses its attention on individuals with complex needs, pioneering health systems across the country have been enhancing programs to better address patients’ medical, behavioral health, and social needs. Through the Complex Care Innovation Lab, a national initiative supported by Kaiser Permanente Community Benefit and led by the Center for Health Care Strategies, many of these innovators come together to accelerate the identification and testing of effective care model enhancements.

Following are presentations from select Innovation Lab participants that showcase emerging best practices for patients with complex needs:

Supportive Place for Observation and Treatment: New Harm Reduction Programming (Boston Health Care for the Homeless, Massachusetts): The current opioid epidemic has disproportionately affected Boston’s homeless population. In response, Boston Health Care for the Homeless created the Supportive Place for Observation and Treatment program, a drop-in facility where those under the influence of drugs such as heroin can be monitored by medical professionals to prevent overdosing. This presentation reviews how the program is designed to simultaneously save lives, reduce emergency department use, and introduce a high-risk, vulnerable population to treatment.


Organizing a Neighborhood Health Resource Workforce Block-by-Block to Support Care and Improve Health in East Baltimore, Maryland (Tumaini for Health, Johns Hopkins HealthCare): In collaboration with the Johns Hopkins Community Health Partnership, Tumaini for Health brings together two community based organizations, Sisters Together and Reaching and the Men and Families Center, to provide targeted health and supportive services to the under-served neighborhood of East Baltimore. This presentation describes Tumaini’s block-by-block approach to coordinating care for residents by using embedded community health workers and peer navigators.


The Center for Health Care Services’ High-Utilizer and Integrated Care Team (The Center for Health Care Services, Bexar County, Texas): This presentation explains how The Center for Health Care Services’ High-Utilizer Program provides integrated care for individuals with complex medical, behavioral health, and social needs. The program’s trauma-informed, strengths-based multidisciplinary care, supported by its Integrated Care Team, has shown substantial cost savings for the population it serves.


ECHO Care: A Program to Care for Complex Patients (Project ECHO, New Mexico): This presentation describes ECHO Care, a program that serves New Mexico Medicaid managed care patients who have multiple poorly controlled chronic illnesses, high rates of inpatient hospital or emergency department use, and/or who may be at high risk of hospitalization. Through team-based, high-intensity primary care, and linkages with specialists as needed through the ECHO Complex Care Clinic, the program helps patients to address social barriers, mental health needs, and care transitions.


End-of-Life Care in a Capitated System: Lessons and Hope for the Future (Commonwealth Care Alliance, Massachusetts): The Life Choices Program is an integrated model that embeds end-of-life and palliative care services within primary care. This presentation outlines the culture and service changes that Commonwealth Care Alliance (CCA) has implemented to provide quality-of-life focused care directed by the patient’s and family’s goals in a way that evolves naturally over the course of an individual’s involvement with CCA.

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