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Health Outcomes Won’t Improve Until We Do This

Why High-Risk, High-Cost Populations and Illnesses Must be Addressed

Live Well San Diego, a long-term effort to improve health and wellness of all San Diego County residents, is frequently cited as an innovative program that looks at health problems holistically and integrates health and human services to achieve better results. According to San Diego County leaders, 3 behaviors (poor diet, physical inactivity and tobacco use) lead to the 4 chronic diseases (cancer, heart disease and stroke, type 2 diabetes and pulmonary diseases such as asthma) that account for 57 percent of deaths, and incur $4 billion in health care costs in the country. 

Working with partners across traditional healthcare, public health, social services, business, education and faith organizations, as well as other community leaders, the county has achieved improvements in conditions that negatively impact population health. San Diego is experiencing reductions in heart disease, stroke, cancer rates, childhood obesity, infant mortality and the number of children in foster care. 

The county is also working to identify high-cost, high-need individuals and improve the coordination of services around those individuals. For example, coordinating mental and behavioral health, substance abuse, housing and employment services for the homeless can reduce taxpayer costs while improving lives and the economic vitality of San Diego. 

This progressive approach of preventing illnesses through proactive measures and coordinating programs across previously siloed organizations is increasingly vital as health care costs soar. According to the Congressional Budget Office, health care accounts for more than 16 percent of the U.S. Gross Domestic Product, and that number is expected to grow. Spending on health accounts for 27 percent of the U.S. federal budget, and Medicaid Programs are the largest component of budgets in many states.

Increasing costs will be exacerbated by an aging population – over the next 15 years, approximately 10,000 people will turn 65 each day. Many of these new seniors are ill-equipped to pay for the care they will need as they age. Currently, more than one-third of all seniors live with incomes below 200 percent of the poverty level. Meanwhile, homelessness, behavioral health issues, substance abuse and physical disability are adding massive costs to government programs.

Leaders are under increasing pressure to rein in spending, while delivering better outcomes and quality of care. These seemingly contradictory goals can be achieved, but require greater efficiency and stakeholder collaboration. A growing number of experts believe that effectively addressing – or at least understanding – the social determinants or factors that influence an individual’s wellness offers tremendous potential to contain or reduce total healthcare and social program costs. Focusing the delivery of services on the holistic needs of individuals and families can yield better results and reduce repeated visits to an emergency room, or readmission to hospitals. This is critical, as one study points out that high-risk, high-need patients make up 20 percent of the US population, yet generate 80 percent of healthcare costs. Additionally, technology can play a significant role to increase independence, improve quality of life and coordinate services for vulnerable populations.

For vulnerable populations, state and federal government leaders must look beyond traditional health care boundaries to address the non-health conditions associated with high-need populations and coordinate to uncover ways to improve the health of families and individuals to contain costs and improve outcomes. 

Effective coordination requires five fundamental processes:

  • Identify – The social determinants of health must be identified and factored into an individual’s care plan.
  • Assess – The individual’s needs must be quantified to determine similarity to other clients and potential costs and risks.
  • Respond – A care coordinator must use the assessment to determine eligibility and entitlement to benefits and services, and then create a care plan that addresses the severity of these needs. 
  • Manage – The individual’s care plan must be managed by a single care coordinator.
  • Measure – Outcomes must be measured at the individual, program and organizational levels.
Learn more about smarter approaches to health and coordinated care. 


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