By Ramona Ramadas, RN
A Tale of Two Problems
JD is at your emergency room - again. He's become so familiar to your staff that they call him by his first name. The visits are always a little bit different, but they are always avoidable. Today he needs a prescription refill. Getting JD this medication seemed like a great plan on paper, but there's more to this patient than meets the eye. He has been in and out of homeless shelters for the past two years. He has struggled with opiate addiction off and on. He alienated himself from friends and family. Every one of these challenges has been a factor in his declining health, and yet these barriers remain unknown to the teams trying to help.
Meanwhile, PJ is about to be released from prison. He served time as a nonviolent offender after stealing a car to help support his drug addiction. He got sober while in prison and finished his GED. He is excited about getting a second chance and desperately wants to help others avoid his situation. But he wonders how he will survive with a criminal record and few employment prospects. For PJ, the stress of re-entering society without a job poses significant risk, with data showing that employment and recidivism are closely linked. PJ's concern has been validated as recently as 2015, when the Manhattan Institute noted that training designed to quickly place former inmates in jobs significantly decreases the likelihood that ex-offenders with nonviolent histories will be rearrested1.
When vulnerable populations fail to get the care or the community support they need, they do not go away, they continue to strain and stretch our systems. In JD's case his high-utilization of the emergency room will continue, his condition will continue to decline, and the social issues he faces may lead to risky decision-making in the future. In spite of the care team’s awareness that nothing is changing for JD, there is no process in place to flag him for an alternate path the next time he presents with an avoidable visit, nor is there anyone on point within the community or the health system that is responsible for JD’s big picture needs and is accountable for better outcomes. And without employment, PJ is at risk for re-entry into the same cycle of risky decision-making that led to his criminal justice involvement.
If these stories hit home for your health system, you are not alone. Patients with low socio-economic status are more likely to use emergency care, are more likely to be admitted, and are more likely to return2. This systemic pattern of vulnerability, infrastructure strain, and individual decline is unlikely to change without new and innovative solutions to the problem.
The current high-utilizer landscape
The good news is that both individual’s needs can be addressed, and this can be accomplished without further strain to the healthcare workforce or the community. Current strategies to improve these issues include use of social workers, emergency department navigators, or even implementation of software that refers patients to community-based organizations (e.g., shelters, or food banks). These programs can move the needle on high utilizers in an emergency room, but they are difficult to develop and sustain with workforce shortages across all roles in healthcare. As a result, workflows and patient oversight fail to follow the patient into the community, where the support is needed the most. And while these programs offer modest success, there is a missing element that is the secret sauce to better outcomes: pairing the patient with a peer who has "been there, done that", has stabilized, and would like to use their experience to help others avoid the same fate. As a result, the patient gets the relatable contact, the peer gets a job, the healthcare workforce gets a new pipeline of workers to add depth to the care team and orchestration of the patient’s needs across the health system and community continuum.
A Tough Value-Proposition to Beat
If you are wondering whether this model can make a difference for your organization, consider this: Memorial Hermann Health System repurposed Community Health Workers (that had peer to peer counseling training) as emergency room navigators between 2008-2011. Pre and post data analysis of this change showed a significant decrease in the volume of visits by one-time high utilizers. Most importantly, the cost to implement and run the program was lower than the savings the health system recognized3.
The emergency room alone is not the only department that can get value out of a peer program. The model can be deployed in primary care, women's health, and many other scenarios.
Building a peer health navigation program is no easy task. There are operational, clinical, and financial considerations that must be surfaced and addressed before putting a program in place. The details of a program range from understanding what a peer's scope of practice should be, how to find and train peers, appropriate interventions, integration into the workflow, how to bill for services, matching peer and patient, and evaluating outcomes. Each one of these is a substantial topic, let alone synthesizing the concepts to construct a program that will offer value to your stakeholders, patients, and staff. Furthermore, while there are formalized training programs that offer peer navigator certification in most states, the content of the training varies from state to state and frequently limits training to a mental health or recovery focus - reducing the peer's ability to contribute to a whole-person care approach.
With a peer health navigation model in place, the next time JD presents to the emergency room, the care team can easily identify him as a high-risk patient and mobilize the right resources to do the right thing for him, at the right time. The Forum team is experienced at designing, implementing and operationalizing sustainable peer programs. Whether you have a program in place and you would like to optimize or expand the peer's scope, or if you are just learning about what a peer program can do - we can guide you toward better outcomes for your vulnerable populations right away.
Ramona Ramadas is an Associate at Forum Solutions and is an actively licensed nurse in Washington State. She has extensive experience in community health and digital health and has won several innovation award competitions with peer-based models of care. She holds a BSN in Nursing from New York University and a Master’s in Healthcare Innovation from Arizona State University.
Forum Solutions is a management consulting firm that works with Seattle’s business and nonprofit leaders to build and implement effective strategies for transformative growth and sustainable results. Forum offers clients the right skills for every job: strategic expertise, lean execution and agile resourcing – improving businesses at any level – from the executive suite to the individual contributor.
1Yellowitz, A. & Bollinger, C. (2015, March 26).
Prison-To-Work: The Benefits of Intensive Job-Search Assistance for Former Inmates. Manhattan Institute. Retrieved from https://www.manhattan-institute.org/html/prison-work-5876.html
2Kangovi, et al. (2013, July). Understanding Why Patients of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care. Health Affairs. Retrieved from https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2012.0825
3Enard, K.R. & Ganelin, D.M. (2013, November-December). Reducing Preventable Emergency Department Utilization and Costs by Using Community Health Workers as Patient Navigators. Journal of Healthcare Management. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142498