Would you share some positive outcomes stories on your Members, after determining social determinants? We have multiple stories, but the one I would really like to share, we do have permission to share this story, and I’ll call it Carol’s Story.  had a series of injuries that required surgeries and she ultimately lost her job. And she tried to make ends meet on disability, but it wasn’t working out for her. It ends, Carol found herself homeless, and for 10 years, she slept in her car, she stayed with friends, slept on the couch, stayed at shelters, and she was wheel chair bound! Shelters proved challenging for her, in fact she got an infection from one, so       very complex; she had diabetes, rheumatoid arthritis, cellulitis, gas- trointestinal issues, trauma, physical and sexual abuse in her early years, and unemployed. Carol’s monthly cost of care ranged about $7400, 35 ER visits, 8 inpatient admits, and 113 inpatient days. This is on any given year for Carol. Through a relationship with one of the downtown shelters in Phoenix, CASS, we were made aware of Carol through a referral about a year ago. We placed Carol in one of our housing units in Maryvale. She is now receiving regular care, I mentioned she was a diabetic, her A1C has dropped, actively working towards self-suf-  her Son who she has not seen in 12 years. She is down to $2000 per month in care with 5 ER visits total over a year, 0 inpatient admits and 0 inpatient days. We are seeing her health outcomes improve, we are seeing her reconnecting in life, and quality of life improve. That is the power of this program the Housing First Model. Obviously we need this program to scale. We need other organi- zations to step up and literally replicate the models that we put out there. We’ve proven that this model can work. We’ve proven what we call a mixed income property can work, meaning you have got a - able housing to individuals ranging from 60% to 120% of average median income, but it also includes a set aside of permanent housing units. It’s been an amazing program for us with amazing stories.


Obviously, the cost of healthcare is soaring, we see it, or hear about it in the news. What is the highest cost in healthcare, and how can we as Members or patients help to reduce that cost? Which diseases are the most costly, and what can Mem- bers or patients do to reduce that cost and feel better? This gets back to that concept 40% health care costs are driven by social determinants. When you think of someone like Carol, very ex- pensive, very complex, type of an individual, those individuals like Carol, those high needs, high risk, high cost members, 22% of the individuals in the United States drive 80% of the health care cost.  The care coordination models we have today, they need to evolve. And that’s probably one of the single greatest things we can do is evolve those models, understand that the culture of poverty is about survival. And the better we understand the culture of poverty the better programs we will be able to develop, but we have to focus in on those social determinants if we truly want to impact lives and tru-  for everyone. The answer lies with more organizations stepping up, making the investments to address the social determinants of health, whether it is through an insecurity or transportation or housing, but we need organizations to make the investment and take the risk, but ultimately it’s building a business case and changing policy, and ad- vocating for policy change and advocating for more dollars invested in social determinants. The reality is, to truly scale this, addressing the needs of social determinants at some point we will need more public support. It’s about two things, one, increasing capacity, providing additional funding to do more and have a broader reach, but it’s also about integration, in fact I think one of the single greatest opportunities


NOVEMBER 2019 I ARIZONA’S OWN MAGAZINE I 7


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