Wraparound Services As a Strategy to Reduce Hospitalizations (AcademyHealth ARM 2018)


Research Objective: One potential strategy to improve patient outcomes and reduce overall health care spending involves including additional providers and experts (e.g., social workers, dietitians, and behavioral health counselors) in conjunction with primary care. These professionals may be better positioned to address the myriad of social, behavioral, and environmental factors that erode health, complicate the care and management of chronic conditions, and increase medical service utilization. The purpose of the current study is to determine if providing these wraparound services within the primary care setting of a large urban safety-net provider was effective in reducing costly health care utilization.

Study Design: The association between receiving wraparound services and utilization outcomes was measured in an 11-year panel of adult patients served by 10 federally qualified health center (FQHC) sites. Starting in 2011, the FQHC increased employment of various wraparound services providers including behavioral health, social work, dietetics, financial counseling, patient navigation, and medical legal partnership. These services were co-located at outpatient clinic sites and primary care providers could make referrals to any wraparound service. We examined within-patient effects of receiving wraparound services on hospitalizations, ED visits, and preventable ED visits using patient-level fixed-effects negative binomial regression models. Each model controlled for time-invariant characteristics and counts of health care encounters and patient severity scores, which could vary annually. Regression models also included indicators for the calendar year to control for secular trends, and robust standard errors to adjust for clustering.

Population Studied: The study sample included adults (18 years and older) who received care between 2006-2016. To be included in the study, patients had to have at least one primary care visit prior to, and one visit after, 2011 (the year wraparound services began being offered). The intervention group were those patients receiving at least one wraparound service. The comparison group did not receive any wraparound services and consisted of up to 4 nearest neighbor propensity-score matched patients. The propensity score matched sample included 13,977 patients with a total of 120,971 person-years.

Principal Findings: In the adjusted model, receipt of any wraparound service was associated with a lower count of hospitalizations in the subsequent year. We observed an 18% reduction in the expected number of hospitalizations in the year following the receipt of a wraparound service (β -0.20; 95%CI = -0.29, -0.12; p <=0.001). Receipt of wraparound services was not associated with subsequent ED or preventive ED utilization.

Conclusions: Patients receiving wraparound services, which include a myriad of non-medical interventions that directly address the social determinants of health, experienced a significant reduction in hospitalizations compared to a matched control group of patients who did not receive those services.

Implications for Policy or Practice: Multiple current US policies are demanding that health care organizations become more attentive to patient risk factors and behaviors that cannot be solely addressed by medical care. Bundled payments, accountable care organizations, and the Hospital Readmission Reduction Program can all put hospital financial performance at risk. Wraparound services may be one part of a portfolio of strategies to address the social, behavioral, and environmental factors that drive poor patient health and increase costs.


Presentations (Oral or Poster)
Vest J, Harris L, Haut D, Halverson P, Menachemi N