How patient experience informed the SafeMed Program: Lessons learned during a Health Care Innovation Award to improve care for super-utilizers

• Published in: Healthcare : the journal of delivery science and innovation Vol. 7; no. 1; pp. 13 - 21
• Main Authors: Nault Connors, Jill D., Binkley, Bonnie L., Graff, J. Carolyn, Surbhi, Satya, Bailey, James E.
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01-03-2019
• Subjects: Care transitions; Patient experience; Patient-centered care; Readmissions; Super-utilizers; Super-utilizers; Care transitions; Patient experience; Patient-centered care; Readmissions
• ISSN: 2213-0764; 2213-0772
• DOI: 10.1016/j.hjdsi.2018.02.002

•Program theory of change must account for the lived experiences of medically and socially complex patients in order to affect dysfunctional patterns of acute care utilization.•Mental and emotional health, access to self-management resources, and patient-provider communication are key issues of importance to super-utilizing patients.•Transformation of didactic, patient education sessions to interactive, self-management support group sessions achieved success in improving patient engagement.•Lack of collaboration and compliance-oriented healthcare culture are primary threats to successful implementation of innovative healthcare delivery programs.•Linkage and navigation roles of healthcare staff are important in improving patient access to existing community resources, but further health system investments are required to effectively integrate community-based and social services into care delivery.•Peer support interventions are underutilized but hold great promise for addressing behavioral health needs of medically and socially complex patients.