Not long ago, Central City Concern recognized a gap in our health services. CCC’s substance use disorder services and specialty mental health services had multiple tiers of programs designed to meet a variety of needs—including acute teams for more complex clients. Our primary care health services didn’t. To fill that need, CCC created the Summit team, a new care team based on the concept of an ambulatory intensive care unit.
Like our substance use disorder and mental health acute care services, the Summit team was designed to serve patients who usually have compound health issues that place them at greater risk for an extra, higher level of care. The team limited its size by design so patients receive streamlined, in-house care from the fewest people possible. “The idea with Summit is to improve care for those who really struggle,” says Matt Mitchell. “So much of the design philosophy around it is: let’s keep it small.”
The team's low patient-to-staff ratio affords patients longer visits, home or in-hospital visits, medication management, enhanced and around-the-clock access, and more. But CCC quickly found that having the Summit team providing care was only half the battle.
“It turns out identifying who Summit patients should be… is really difficult,” Matt says. By virtue of the type of care the Summit team provides, the criteria for pinpointing patients—advanced illness that’s expected to deteriorate without more intensive care, isolation, a need for extensive medication management, medical complexity driven by untreated or severe behavioral health condition, among others—is only partially helpful.
“There are over a thousand patients who can check all the right boxes on that [criteria] form,” says Matt. “But Summit isn’t meant to serve all of those patients.”
Identifying patients who would be best served by Summit is a balancing act.
“On one hand, the Summit team is trying to organically figure out who they can best serve and who’s right for Summit. The clinical judgment of the providers is so important.”
Matt, a data and quality specialist assigned to work exclusively with the Summit team, supplements their judgment with data. “On my end, I’m trying to do the same thing in parallel, but with data analysis to identify who are the highest risk patients we serve at Old Town Clinic [CCC’s primary care health center].”
When it comes to the care of patients as vulnerable as those Summit seeks to serve, it would be easy to choose sides or put more faith in one approach
over another. Providers versus p-values. Informed hunches versus analysis. Matt doesn’t see it that way. In fact, he believes utilizing a balance of
both approaches ultimately serves patients better.
“The clinical judgment piece is so important because there are things we just don’t have data on. Data isn’t truth, it gives us some ideas of where to go,” he says. “But I think it’s really important to put data in front of clinical staff and decision makers to help remind them of things they wouldn’t have thought about otherwise.”
Matt’s role as the Summit team’s dedicated data analyst has proven to be incredibly beneficial to the way he is able to support the aims of the team. He sits in on each morning’s team huddle, participates in their discussions about patients and priorities, and is part of the team’s thought processes—activities reminiscent of the time he spent as a Boston-area outreach worker.
“Understanding what’s happening on the ground and having an idea of what the patients’ stories are helps me understand the limitations of the data so that ultimately I can use that data more appropriately and effectively,” Matt says. “Otherwise I’m looking at numbers and statistics all day. Our patients are more than that.”
In addition to analyzing and incorporating data to identify Summit patients, Matt is working on an exciting project that visually maps out the characteristics of all Old Town Clinic patients, onto which he’ll overlay Summit patients data points to identify areas they tend to cluster. “Hopefully this will give us a new perspective on identifying the patients who are really right for Summit,” he says.
The benefits of this innovative solution won’t be confined to Summit. Matt plans to use this project to explore patients of other specialized teams at CCC, like Community Outreach Recovery & Engagement (CORE) and Integrated Health & Recovery Treatment (IHART).
Matt relishes the freedom he has as Summit’s data analyst to sit with and think through problems. Ultimately, his approach, process, and solutions end up being richer and deeper, which means his work can be valuable beyond Summit.
“Our hope is that Summit can operate like a learning lab for the rest of Old Town Clinic, and ideas and things we pilot can be expanded elsewhere.”
And even when he finds himself deep in numbers, formulas, and maps, Matt is intentional about not losing sight of the people Summit serves.
“I love these patients; this is a population I care about. It’s important to me to use data to ensure that people get the things they need.”
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