TY - JOUR
AU - S. R. Sioni
AU - L. Manson
AU - N. Arledge
A1 - 
AB - High-need, high-cost (HNHC) adults require comprehensive strategies that address both clinical and social determinants of health (SDOH). This retrospective, propensity score-matched study (n = 526) evaluated a care model integrating monthly SDOH screenings, medication oversight, and real-time admission-discharge-transfer alerts in four urban primary care clinics. Compared to usual care, the intervention significantly reduced acute utilization within 60 days: emergency department (ED) visits decreased by 0.17 (P < 0.001) and hospital admissions declined by 0.12 (P < 0.001). Gross per-participant costs fell from $6,019 to $2,422 (a $3,597 reduction); after accounting for intervention expenses, net savings reached $3,222 (P < 0.001), yielding an estimated 6.9:1 return on investment. Patient-reported outcomes also demonstrated significant gains: EQ-5D-5L scores increased by 0.082 (P < 0.001) in the intervention cohort, exceeding the threshold for clinically meaningful change, while Net Promoter Scores rose by 8.8 points (P < 0.001). Subgroup analyses revealed slightly smaller quality-of-life gains among non-White cohorts, highlighting the need for culturally tailored approaches to advance equity. These findings align with prior Population Health Management research showing that integrated care models can reduce costs and enhance patient satisfaction. Overall, this multifaceted model effectively curbs avoidable ED visits and admissions, generates short-term cost savings, and boosts patient satisfaction-key outcomes under value-based care contracts. Future research should investigate longer-term outcomes and refine equity-focused strategies to ensure sustained and inclusive benefits.
AD - College of Health Solutions, Arizona State University, Phoenix, Arizona, USA.; Carlsbad Medical Center, Carlsbad, New Mexico, USA.
AN - 40152892
BT - Popul Health Manag
C5 - Financing & Sustainability
CP - 3
DA - Jun
DO - 10.1089/pop.2024.0245
DP - NLM
ET - 20250328
IS - 3
JF - Popul Health Manag
LA - eng
N2 - High-need, high-cost (HNHC) adults require comprehensive strategies that address both clinical and social determinants of health (SDOH). This retrospective, propensity score-matched study (n = 526) evaluated a care model integrating monthly SDOH screenings, medication oversight, and real-time admission-discharge-transfer alerts in four urban primary care clinics. Compared to usual care, the intervention significantly reduced acute utilization within 60 days: emergency department (ED) visits decreased by 0.17 (P < 0.001) and hospital admissions declined by 0.12 (P < 0.001). Gross per-participant costs fell from $6,019 to $2,422 (a $3,597 reduction); after accounting for intervention expenses, net savings reached $3,222 (P < 0.001), yielding an estimated 6.9:1 return on investment. Patient-reported outcomes also demonstrated significant gains: EQ-5D-5L scores increased by 0.082 (P < 0.001) in the intervention cohort, exceeding the threshold for clinically meaningful change, while Net Promoter Scores rose by 8.8 points (P < 0.001). Subgroup analyses revealed slightly smaller quality-of-life gains among non-White cohorts, highlighting the need for culturally tailored approaches to advance equity. These findings align with prior Population Health Management research showing that integrated care models can reduce costs and enhance patient satisfaction. Overall, this multifaceted model effectively curbs avoidable ED visits and admissions, generates short-term cost savings, and boosts patient satisfaction-key outcomes under value-based care contracts. Future research should investigate longer-term outcomes and refine equity-focused strategies to ensure sustained and inclusive benefits.
PY - 2025
SN - 1942-7891
SP - 161
EP - 172+
ST - Short-Term Gains, Enduring Potential: An Integrated SDOH-Focused Care Model Delivers Cost Savings and Patient-Reported Benefits
T1 - Short-Term Gains, Enduring Potential: An Integrated SDOH-Focused Care Model Delivers Cost Savings and Patient-Reported Benefits
T2 - Popul Health Manag
TI - Short-Term Gains, Enduring Potential: An Integrated SDOH-Focused Care Model Delivers Cost Savings and Patient-Reported Benefits
U1 - Financing & Sustainability
U3 - 10.1089/pop.2024.0245
VL - 28
VO - 1942-7891
Y1 - 2025
ER -