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

Abstract

• 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.