Short-Term Gains, Enduring Potential: An Integrated SDOH-Focused Care Model Delivers Cost Savings and...

Area of Science:

• Healthcare Management
• Population Health
• Health Equity

Background:

• High-need, high-cost (HNHC) populations require integrated care addressing clinical needs and social determinants of health (SDOH).
• Existing care models often fail to comprehensively manage HNHC adults, leading to high healthcare utilization and costs.
• Effective strategies are needed to improve outcomes and reduce expenditures for this vulnerable group.

Purpose of the Study:

• To evaluate an integrated care model for HNHC adults in urban primary care settings.
• To assess the impact of the intervention on acute healthcare utilization, costs, and patient-reported outcomes.
• To identify potential disparities in outcomes and inform equity-focused strategies.

Main Methods:

• Retrospective, propensity score-matched study of 526 HNHC adults across four urban primary care clinics.
• Intervention included monthly SDOH screenings, medication oversight, and real-time admission-discharge-transfer (ADT) alerts.
• Comparison against usual care to determine the model's effectiveness.

Main Results:

• The intervention significantly reduced emergency department (ED) visits by 0.17 (P < 0.001) and hospital admissions by 0.12 (P < 0.001) within 60 days.
• Gross costs per participant decreased by $3,597, with net savings of $3,222 (P < 0.001), a 6.9:1 return on investment.
• EQ-5D-5L scores improved by 0.082 (P < 0.001) and Net Promoter Scores rose by 8.8 points (P < 0.001).

Conclusions:

• The integrated care model effectively reduced acute utilization and generated significant cost savings for HNHC adults.
• The model improved patient-reported quality of life and satisfaction, aligning with value-based care goals.
• Culturally tailored approaches are needed to address smaller quality-of-life gains observed in non-White cohorts and advance health equity.