Super-Utilizer Fellows Reflect on a Year of Service with the Coalition
By Drs. Steve Sluck and Stephanie Watkins
Our year with Camden Healthcare Coalition and Abigail House hasn’t just made us better doctors, it’s made us better people.
Care systems and the health care professionals within them too often forced to approach patients as problems to be solved: the day is busy, discharges are made quickly, and little high level tactical solutions can be applied to high risk and high user patient groups. Symptoms lead to a diagnosis and then a treatment. But patients are more than textbook problems: sometimes treatment works better or worse than expected. Sometimes a patient doesn’t take their prescribed medication as directed; sometimes they take the wrong one or too much. All too often the same patients are readmitted numerous times for the same ailments without any in-depth exploration of why.
Our fellowship at Abigail House has allowed us to take in the 5000-foot view on a patient as a whole person. We investigate high use patients in the context of their entire lives, how they feel about their health care experience and how it affects their personal health choices. To see how the real source of illness might be something a blood test can’t identify: difficulty of communication, emotional isolation, poverty, or discouragement with the possibility of actually getting better.
One patient we interacted with at Abigail House had never been to the hospital before. And then in a six-month period, they went into the hospital, back home, into rehab, home again, and into rehab a second time. Six different care settings in six months. Naturally this person was confused and discouraged. It’s a common situation and one that highlights the breakdown in coordination between care-giving organizations.
We’ve had the great fortune of working with a dedicated and immensely talented network at both Abigail House and the Camden Coalition, including a behaviorist, pharmacist, psychologist, social work student, pharmacy student, risk care manager, data scientists, lawyers, and passionate, hard-working care teams and nurses. However, perhaps the most valuable factor in patient’s health is a caring, supportive family. Particularly for patients with cognitive deficits, the difference family support can make is enormous.
We have learned a great deal in our fellowship activities so far, but even more exciting is the work yet to be done. We both know this perspective altering experience will enrich our medical work throughout our careers. We also hope that fellows at Abigail House in future years can create and execute specific intervention approaches based on our research.