After partnering last year with the nonprofit Camden Coalition to launch the ONE Health population health strategy, Regional One Health already is seeing strong results in the reduction of emergency room visits and the associated costs from the system’s highest emergency department utilizers.

Regional One’s top 25 “super-utilizers” averaged 85 hospital visits each over the past year, and the highest utilizer clocked in at 195 visits. The hospital is looking to identify the root cause of those visits, which amount to a huge cost each year, and then help connect those patients with the appropriate community resources.

Regional One discussed the program’s progress Tuesday, June 26, during an update luncheon Neighborhood Christian Centers Inc., a partner organization, hosted at its 785 Jackson Ave. location.

Neighborhood Christian Centers President and CEO Ephie Johnson talks about working with the less fortunate at a ONE Health update event on June 26. (Michael Waddell)

“If you look at the data, what you will see is that your health is only about 20 percent attributable to the care you receive in the clinic or hospital,” said Susan Cooper, Regional One chief integration officer. “What really determines your health status are the social determinants of health like poverty, education, your physical environment and what social supports you have. So why are we spending the majority of our health care dollars on health care and not investing in social services?”

Overall, Regional One has identified more than 21,000 super-utilizers, patients who had four or more hospital in-patient visits per year or 10 or more emergency department visits per year.

The first few months of the ONE Health initiative was about drilling down into the data and mapping community resources. Data were analyzed for patterns and reasons these patients came to the emergency department so often, which led to the creation of an online resource that anyone in the community can use to locate free and reduced-cost services in ZIP codes throughout Shelby County.

In the program’s second six months, the hospital began engaging with patients who make high numbers of emergency room visits. The research found that in many cases, factors beyond medical reasons bring individuals to the ER, or the medical reasons they have for seeking care are caused or made worse by circumstances in their environments, including poverty, food insecurity, homelessness, mental illness and job loss.

“Some people are only in the program for a few days. Their problems might be very easily rectified [such as a medication issue], so they may be with us for 30 days and then they revolve out of the program,” said Tammie Ritchey, head of the Regional One Foundation, which helped to get funding for the initiative. “Then there are others who will be with us for a long time because there is addiction, homelessness or mental health issues.”

The ONE Health project, funded in part by The Assisi Foundation, is estimated to cost about $4 million over a three-year period.

Today, 34 patients are enrolled in ONE Health, and the outcomes so far have been positive, according to hospital leaders. Regional One is connecting them with resources in the community, which leads to better health outcomes and fewer visits to the hospital.

“My mom had the vision to serve people where they were, to meet people where they were, to be a voice for the voiceless, to serve them at their lowest need and them help them move toward sustainability,” said Ephie Johnson, president and CEO of Neighborhood Christian Centers Inc., which last year served 53,000 people in need at its seven area locations. In August, the nonprofit will open its eighth location in Southeast Shelby County.

The ONE Health initiative is the result of a partnership with the New Jersey-based Camden Coalition, a nonprofit that works to improve health and reduce costs. With Camden Coalition’s help, Regional One estimates it can save more than $1 million by targeting high utilizers.

“Activities going forward for the next six months are we’re in the process of hiring our second care team,” Cooper said. “We’re in the process of putting together a community care plan [that will link patient care at different area emergency departments], and we’re in the process of developing our own student hot-spotting program.”

The hospital has determined that if it achieves the financial outcomes it is working toward during the three years of the ONE Health program, in the fourth year the system will be able to sustain and fund the program itself.