Wellness Care Plans: An innovative approach for high-needs healthcare users

Healthcare organisations are continually looking for ways to address the needs of ‘high utilisers’ of their systems. Southcentral Foundation (SCF), an Alaska Native customer-owned healthcare system located in Anchorage, Alaska, employs an innovative approach to working with these patients (who are called ‘customer-owners’ at SCF). SCF does not restrict these customer-owners from accessing the healthcare system; rather, SCF works with these customer-owners to create a Wellness Care Plan to help them reach health goals they and their primary care provider set while working together with a behavioural health consultant. Once goals have been set, the customer-owner’s integrated care team handles follow-up, and the plan is noted at the top of the customer-owner’s Electronic Health Record (EHR) so that any other providers they see have easy access to it. Goals and action items are tracked in the EHR and collated in SCF’s Data Mall. Data are also tracked on the number of reactive and proactive visits the customer-owner makes, to help their care team evaluate the effectiveness of the Wellness Care Plan. SCF has seen increased rates of healthcare quality for customer-owners on Wellness Care Plans, which indicates that a collaborative approach to working with high-needs patients can achieve positive results when the system works to support this kind of approach. Studying SCF’s Wellness Care Plans may prove valuable for other healthcare organisations struggling to help high-needs patients.