Open Minds Senior Associate Brandon Danz, MHA, MPA, expanding on his theory of a burgeoning market of “superutilizers” (i.e., patients with chronic, complex physical and behavioral health conditions, often compounded by the need for social services and supports) identified the core elements of a care management program for such patients:
- Comprehensive care management
- Care coordination and health promotion
- Improved communication and coordination of health information technology to link services
- Individual and family support
- Face-to-face care management
- Specially-trained care managers and small caseloads
Danz points out that telehealth services may not be an ideal solution for superutilizer patients, suggesting instead to consider in-home services:
Care management of superutilizers cannot be done solely over the phone. Many superutilizers have health care conditions and human service needs that are too complex to manage from a distance. Transportation challenges are also common, making it difficult to maintain appointments. For these reasons, home visits should be part of your care arsenal.
Danz recommends that a nurse-led care team of a social worker, physician, behavioral health worker, and any other specialty care practitioners as necessary be assigned to each superutilizer patient. He adds:
Most of the work will be shouldered by the nurse and a social worker. These members of the team will focus on two strategies – promoting consumer engagement and utilizing home visits to understand the consumer’s needs. The nurse and social worker will keep the other members of the care team informed about the consumer, and the entire team will work together to develop objective, measurable goals for the consumer’s health improvement.