Community-based care management programs for patients with complex health and social needs have the potential to reduce hospitalizations and inpatient costs.
Rhode Island implemented a community-based care management program called the Community Health Team (CHT) program for individuals with high health care utilization. The CHT program engages a multidisciplinary team to serve as an extension of primary care and offer social and behavioral health support, care coordination, and nonmedical support, such as applications to social services programs (e.g., housing, transportation, financial resources). This study of a CHT program at a federally qualified health center used claim and enrollment data to compare more than 2,000 patients seen by the CHT with those in a comparison group.
Individuals participating in the CHT experienced about seven fewer hospitalizations per 1,000 people per month. Inpatient costs also decreased by $289 per person per month. This study was not restricted to patients with a specific health plan or chronic condition, which allowed the study to examine outcomes from the CHT program in a more general population. Three different subgroups were created based on the number of interactions with the CHT ( low, medium, and high). The impact of the CHT differed across the three subgroups with the low group experiencing the greatest decreases in hospitalizations and costs. The finding about this subgroup may indicate that the health care costs and utilization of patients in this subgroup were less complex and could be more quickly addressed by an intervention such as CHT.
Providers and health systems, plans, and other states can consider implementing a similar model to the Rhode Island CHT to help connect patients with social and behavioral health supports while also lowering utilization and costs