A recent report by the Pennsylvania Health Care Cost Containment Council, known as PHC4, focused attention on patients with complex health and social needs (described as “super utilizers”). These patients often use a disproportionate amount of hospital services. The PHC4 report looked at nearly 22,000 Pennsylvanians who were admitted to their local hospital more than five times in 2016. While these patients accounted for just 3 percent of all hospital admissions last year, they accounted for 10 percent of hospital costs (about $1.25 billion). Most of that cost was paid for by the taxpayer funded Medicare and Medicaid programs.

Big numbers, for sure, but the trend is positive. Hospitals and health systems across the commonwealth have developed innovative programs to address the often-complex and multifaceted needs of these patients. These programs are making a difference. In 2014, more than 24,000 Pennsylvanians fell into the “super utilizer” category; last year the number was just under 22,000. Lancaster County is making remarkable progress. In 2012, we ranked sixth in the state for the number of these complex patients per 10,000 residents (12.9); last year we ranked second (11). These programs are beginning to gain traction and should be expanded.

Lancaster General Health calls its program to help these chronically ill patients “Care Connections.” Care Connections brings a range of expertise and support to each patient and looks at each patient’s health situation in a holistic manner. Not surprisingly, the patients enrolled in Care Connections often have multiple and long-term health challenges that can include physical ailments, mental health issues and addictions. Difficult social, family or economic conditions can also contribute to frequent emergency visits and hospitalizations.

The treatment teams in Care Connections include physicians and nurses, of course, but can also have physical therapists, pharmacists, nurse practitioners, behavioral health counselors, social workers, addiction experts and even attorneys. We also work closely with many community-based organizations and agencies that provide important support. In this fashion, the Care Connections team develops a comprehensive plan for each patients’ needs.

This approach benefits the broader Lancaster community. Among the more than 400 patients enrolled in Care Connections since the program’s beginning in August 2013, LGH has measured a 42 percent drop in emergency department visits and a 54 percent drop in the number of admissions to LGH. Avoiding unnecessary visits relieves emergency department crowding. The drop in utilization also generates significant reductions in costs associated with caring for these patients.

For the patients themselves, Care Connections often represents a chance to regain a sense of hope and control over their health and their lives. Managing diabetes can be difficult under the best of circumstances. Managing diabetes while also struggling with depression, unemployment, lack of transportation and dysfunctional family relationships is often overwhelming. Without the coordination and support offered by Care Connections and similar programs, patients often simply drift from one health crisis to the next.

Take the case of Jose (not his real name). Dangerously overweight and depressed, and struggling from a host of related pulmonary and circulatory diseases, Jose frequently arrived at the hospital emergency department in crisis. After he enrolled in Care Connections, our team coordinated a range of interventions that helped Jose get counseling, address his medication needs and lose weight. His overall health improved and today Jose volunteers in LGH’s physical therapy department and with the Care Connections program, supporting other enrollees.

Or consider the case of Sylvia (not her real name), a middle-aged woman suffering from kidney disease, hypertension and diabetes. Sylvia enrolled in Care Connections after a series of frequent emergency visits. The care team discovered that Sylvia also suffered from an underlying chemical addiction and an abusive relationship in her home. Interventions for these issues put Sylvia on a path to recovery and virtually eliminated related emergency visits to the hospital.

Programs such as Care Connections represent a significant investment in improving the value of healthcare, and they address the need for hospitals and health systems to focus on the overall health of the community and not just on acute episodes of care.

Lancaster County can take pride that we are making progress in what has been a long-term problem. As our nation debates the elements of health care reform, Care Connections and other holistic approaches to health should be embraced and expanded.

Dr. John Wood is medical director of Care Connections. Dr. Jeffrey Martin is lead physician extensivist of Care Connections.

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