The Patient Health Improvement Initiative works in a special way to help chronically ill patients in communities in San Diego County with the highest disease burdens and highest death rates.
Once an individual meets the enrollment criteria, a team of medical and social specialists begin working closely with him or her.
The team includes a nurse case manager, a social worker, community health workers and faith-based volunteers. They work intimately with each patient, including visiting his or her home, to help manage chronic illnesses, to coordinate medications and therapies and to accompany them to their appointments, all the while offering emotional and spiritual support.
This patient-centered approach sounds expensive but preliminary data is showing that it’s achieving significant cost savings. The first 117 participants, for instance, reduced their visits to the emergency room by 31 percent, hospital admissions by 22 percent, and hospital length of stay by 49 percent, compared to the period before enrolling.
Of those, a cohort of 21 participants who belonged to one health plan saved nearly $660,000 in a year, down from $1,625,000 in healthcare costs the previous year.
In all, preliminary data shows that for every dollar spent on the project, $5 was saved. Every patient is different, but most experienced a significant improvement in their health and life.
“I was going to the hospital all the time,” says one of the participants, Jesús Mendoza, who is battling a severe kidney ailment. “Now, I have learned how to care of myself.”