New, Dedicated Care Team Serving High-Risk Population

Individuals with chronic illnesses, behavioral health issues and personal barriers to accessing good healthcare don't always know where to turn. Often, the Emergency Department is the most convenient way to get care when they need it, but it doesn't truly help them get well.

GBMC's new Complex Care Team does.

Early in 2019, GBMC identified "high utilizers" of hospital services, defined as three or more hospitalizations or visits to the ED in a calendar year.

Currently, the four-person Complex Care Team has been seeing about 25 patients over a three-month period – weekly or even daily, depending on the individual patient's needs. The team manages complex needs – often a combination of chronic illness, behavioral health challenges and substance abuse. A personalized health plan is created for each, and the team also looks at social determinants of health – money, time, transportation – and looks to remove those barriers to care.

One patient's job required him not to miss a day or he would be fired. But the medication he required could only be administered during his working hours. In the traditional system, he might have fallen through the cracks. But the Complex Care Team arranged his medication for a time more convenient to his lifestyle.

This type of intense intervention has been successful thus far to the patients served, with less than five needing to be readmitted after working with the Complex Care Team. The hope is, once the barriers to care have been improved, the patient will return to their primary care provider, if they have one, or be followed in one of the multiple primary care offices of GBMC Health Partners for ongoing management.

Thanks to Mark Lamos, MD and Vaibhav A. Parekh, MD, they now have a plan.