PP02 – Caring for People with Complex Health and Social Needs
Complex individuals who have chronic illness coupled with substance abuse, behavioral health needs, limited health literacy, and/ or unstable environments tax the health system and have less than optimal health outcomes. Healthcare research has shown that social circumstances and behavioral patterns combined account for 80% of health outcomes more than clinical risk. Reduced hospital admissions and increased wellness activity have been achieved through engagement of high risk populations and attention to basic needs such as employment, housing, food security, financial assistance, transportation, etc. The multidisciplinary team is comprised of nursing and social work professionals under physician and social work leadership. An individual’s participation in the program is voluntary. Team members engage individuals in flexible treatment plans based on the person’s unique needs and his/her stated goals. Through the formation of trusted relationships, the team engages the most complex individuals on their health, empowering them to manage their own care environment and longitudinally care for themselves and their address their needs. Education and empowerment is the goal. A full assessment is completed on all program members and a personalized care plan is developed. The relationship is the vehicle to identify and address social determinants of health one at a time. Carelink CareNow Community Team engages high risk individuals and leverages relationships within the state and community to develop collaborative individualized care plans that comprehensively address medical, social, and environmental needs. The key to success is developing authentic trusting relationships and employing comprehensive, personalized wellness strategies which are flexible and creatively leverage existing resources. This has reduced acute care usage by 37% through stabilization of both medical and social needs.