This resource describes a new model that moves high-need patients out of the emergency department and into a network of social supports.
- Regional One Health, a large health system in Tennessee, has built established a program called ONE Health that combines data analysis and community connections and is led by a team of nurse leaders experienced in complex care.
- The ONE Health team identifies eligible patients, facilitates care coordination, connects them to social services, and then moves them to a place where they can care for themselves.
- An important part of the model is developing “authentic healing relationships,” in which a health provider develops a secure and genuine connection with a patient.
Among a set of high utilizers, the program reduced uninsured ED visits by 68.8 percent, inpatient admissions by 75.4 percent, and lengths-of-stay by 78.6 percent—saving $7.49 million over a 15-month period.