Wellness Planning for High-Needs Health Care Users: A Collaborative Approach

Many health care organizations are looking for ways to better serve “high-needs” patients, i.e., patients who make a lot of visits to the health care system. At SCF, we favor a collaborative, relationship-based approach to working with “high-needs” customer-owners. When a customer-owner begins to utilize the health care system at a high rate, we do not scrutinize them, restrict visits, or assign them a different case manager or care team. Rather, we look for ways to partner with the customer-owner and ensure that we are supporting them in stabilizing and treating their health issues.

One method by which we support “high-needs” customer-owners is our Wellness Care Plans. These are wellness plans created with providers and customer-owners working in partnership, and the plans are aimed at reaching the customer-owner’s health goals. The benefits of these plans are numerous and include the following:

They allow providers to work together so that the customer-owner does not have to start over with each new provider
They ensure that customer-owners understand their health conditions
They allow the customer-owner to be an active manager in their health care
They define health goals and outcomes
They ensure that family and/or friends understand the plan and can assist in supporting the customer-owner

The wellness planning process begins with the primary care provider working together with the customer-owner to identify health needs and concerns (as defined by the customer-owner). Both short-term and long-term goals for the plan are established; for example, a customer-owner might have a goal of achieving a 5 pound weight loss in six weeks. These goals are tracked once the plan is implemented, and the plan can be adjusted if there are problems that arise along the way.

After the Wellness Care Plan is in place, care is coordinated with the aim of helping the customer-owner reach the goals in the plan. This may include other health resources available on SCF’s campus such as health education, behavioral health, etc. Care management and follow-up tasks are not specific to members of an integrated care team, which gives teams the flexibility to decide the best management plan and strategies for implementation. Each integrated care team decides who will manage the wellness plan and how follow-up will be handled.

Wellness Care Plans have proven successful in helping customer-owners achieve better health outcomes. Customer-owners who have been on a Wellness Care Plan in the last three years exceed the 90^th percentile in Healthcare Effectiveness Data Information Set (HEDIS) measures such as cervical cancer screening, colorectal cancer screening, and diabetes HBA1C screening. And emergency department visits per 1,000 member months have dropped by 28 percent among these customer-owners.

Our experience with Wellness Care Plans demonstrates that taking an inclusive approach and working proactively with high-needs customer-owners can help them better manage their own health, achieve better health outcomes and reduce their dependence on the health care system. This accomplishment requires a shift in how we approach these customer-owners and their interaction with the system. Instead of focusing on the number of visits they make, the focus should be on why they are making those visits, and how to make those visits begin to better support their complex health needs.