Models for Caring for Patients with Complex Lifestyle, Medical, and Social Needs

A small fraction of the US population accounts for the majority of the country’s healthcare spending. Patients who are frequently hospitalized tend to experience multiple chronic conditions, often brought on and exacerbated by environmental and lifestyle factors. The current standard of care, though, has become highly fragmented as the healthcare system has become increasingly specialized. Typically, a hospital-based physician cares for patients when they are hospitalized and primary care physicians care for them in the outpatient setting. Addressing these complex medical conditions and social needs requires a multidimensional and integrated approach to care. To meet these needs, a model has been developed for patients at increased risk of hospitalization by offering them care from the same physician in both the hospital and the clinic. This physician model was enhanced by developing the Comprehensive Care, Community and Culture Program, which adds systematic assessment for unmet social needs and access to a community health worker and community-based arts and social programming. By assessing unmet social needs, the team identified a cluster of needs that included healthy eating, physical activities, and social engagement. The team also designed an intervention referred to as the Healthy Living Program to address this cluster of needs through an integrated program that includes healthy eating curricula, community gardening, and physical and mindfulness exercises. The Healthy Living Program addresses this cluster of needs in an efficient and low-cost manner, facilitating application to other settings.