Introduction

A groundbreaking project in San Diego County is transforming the lives of the neediest patients while cutting healthcare costs. Early results offer a powerful prescription for underserved communities and the healthcare system struggling to treat the chronically ill.

The three-year project is called the Patient Health Improvement Initiative (PHII), the inaugural program of the Multicultural Health Foundation. It’s being funded by a $1.1 million Healthcare Innovation Challenge Grant. The grant was won in 2012 by a San Diego group of independent physicians, the Multicultural Primary Care Medical Group, in collaboration with the San Diego Organizing Project and local and national partners.

The project works with chronically ill patients reeling from one medical crisis to another, frequently landing in emergency rooms, racking up expensive bills. These patients are generally stabilized and sent home alone, unsure how to manage their multiple ailments, often facing serious social problems, such as inadequate housing, and a lack of transportation and food.

The project turns this cycle on its head.

An entire care team works closely with patients for up to 12 months to meet their immediate health needs and tackle the major social problems affecting their health. The goal is to make a long-term impact on the individual’s quality of life, which in turn helps their families, communities and the health-care system.

The results so far show that most patients are able to stabilize their health, reducing their visits to the emergency room and hospitalizations. This, in turn, is yielding significant cost savings to the health-care system, which benefit ratepayers and tax payers — virtually everyone who uses the system. A portion of these savings are being reinvested to help patients from regressing to medical crisis and to expand the number of patients served.

That’s why this patient-centered approach holds such promise as a compassionate, cost-effective, long-term solution to treat the chronically ill.