Working With Socially and Medically Complex Patients: When Care Transitions Are Circular, Overlapping, and Continual Rather Than Linear and Finite.

The care coordination program described here evolved from 5 years of trial and learning related to how to best serve our high-cost, high-utilizing, chronically ill, urban core patient population. In addition to medical complexity, they have daily challenges characteristic of persons served by Safety-Net health systems. Many have unstable health insurance status. Others have insecure housing. A number of patients have a history of substance use and mental illness. Many have fractured social supports. Although some of the best-known care transition models have been successful in reducing rehospitalizations and cost among patients studied, these models were developed for a relatively high functioning patient population with social support. We describe a successful approach targeted at working with patients who require a more intense and lengthy care coordination intervention to self-manage and reduce the cost of caring for their medical conditions. Using a diverse team and a set of replicable processes, we have demonstrated statistically significant reduction in the use of hospital and emergency services. Our intervention leverages the strengths and resilience of patients, focuses on trust and self-management, and targets heterogeneous "high-utilizer" patients with medical and social complexity.