One Health Team

Where a passion for patient care and the desire to make a difference in the community meet, there is Regional One Health’s ONE Health Complex Care program. Complex care programs are designed to better address the needs of patients with multiple health and social needs who require a coordinated and comprehensive approach. These programs aim to not only improve patient outcomes, but also manage health care costs more effectively. The ONE Health program is one such program. It was started after Regional One Health recognized an issue with high emergency department utilization, with a small group of patients accounting for a large percentage of visits and costs.

In Memphis, some patients would come to the ED because it was the only place they could get medications for chronic conditions or the only place they could find food or shelter. Nationwide, there is an increasing recognition of the need for an integrated care model that addresses multiple facets of a patient’s health. These programs represent a significant advancement in how health care systems address the needs of patients with complex conditions, reflecting a more holistic and patient-centered approach.

One of the pioneers in the field is our very own Susan Cooper, Regional One Health Senior Vice President and Chief Integration Officer. She shares the inspiring journey and its significant impact with a compassion, dedication, and commitment to improving the lives of those she serves. “The genesis of the ONE Health program stemmed from a deep-seated desire to address the needs of uninsured individuals,” Susan explained. The lack of insurance often meant that people without coverage would turn to the emergency department as their primary care solution – and this frequent, emergency-based approach was not only inefficient but highlighted a broader issue. Susan explained that understanding the magnitude of the problem required a meticulous analysis of data. “We had to go to the data and take a look at the data to say, OK, we believe that there are some people who are frequently utilizing the emergency department.” This data-driven approach revealed the astonishing frequency with which certain individuals were using emergency services. The data at that time surprised both Susan and Dr. Reginald Coopwood, the President and CEO at Regional One Health.

ONE Health serves uninsured, Shelby County adults with high utilization of health care by helping them access medical care and address health-related social needs such as housing, transportation, and food. These patients, averaging 50 years old, often have three to five chronic conditions and face significant challenges, including unstable housing or homelessness, food insecurity, complex behavioral health issues, and lack of insurance.

Susan is still amazed at the staff, the impact that they have made, and the unyielding commitment to making a difference. One such trailblazing staff member, Megan E. Williams, the Director of Complex Care at Regional One Health, began her career in Memphis in 2018. She earned her master's degree as a clinical nurse leader and worked in various roles, focusing on complex patient situations for more than a decade. Her role has been instrumental in expanding services and improving patient outcomes by integrating community resources and addressing critical social determinants of health.

"I started intervening on about 30 to 50 patients myself, seeing trends in why they were coming into the hospital all the time," she explained. This hands-on approach allowed her to identify and address recurring issues effectively. ONE Health’s internal complex care model now uses a more comprehensive set of 13 domains to more precisely assess, identify, and address patient needs. "Our highest domains are food insecurity and transportation needs," Megan said, reflecting the ongoing areas of concern that the program continues to address.

Through whole-person care and accelerated access to services, ONE Health aims to improve the health, self-sufficiency, and well-being of uninsured men and women with complex social and medical needs. By connecting patients with appropriate levels of care, the program strives to reduce unnecessary emergency department visits and inpatient hospitalizations, thus bending down the financial cost curve.

Megan specifically emphasizes the challenges of coordinating care across systems within the hospital and the community. The importance of breaking down “silos” among various service agencies refers to the isolation and boundaries between units in a health system.  When departments and agencies operate independently, it can lead to fragmentation of care, medical errors, high costs, and poor patient outcomes. In a silo-type environment, information sharing is limited and collaboration across agencies is minimal.

Megan explains how the ONE Health program at Regional One Health collaborates with various community and institutional partners to avoid working in “silos." They coordinate with entities such as the Community Alliance for the Homeless and MIFA, which provide critical support services.

The ONE Health team consists of registered nurses, social workers, a data analyst, and a complex care clinical director, some of whom daily round in the emergency department and inpatient units to connect with patients. Every patient is screened for eligibility for insurance, food benefits, and appropriate housing placement. Collaborating with over 100 community agencies, the team creates comprehensive care plans to address patients' unmet needs.

Ashley Eleby, the Supervisor of Complex Care Case Management, is one such remarkable team member. She began her career at Regional One Health in 2019 after 15 years in health care, beginning with lab science and transitioning into nursing in 2013. Her early experiences included working as a discharge nurse, where she managed the discharge planning for up to 25 patients a day. Through this role, Ashley observed a troubling disparity when patients without insurance often lacked adequate discharge plans and resources. This motivated her to seek a role where she could make a more impactful difference. She was struck by how complex care aligned with her passion for addressing gaps in patient care and was eager to get involved.

The program’s daily operations include running reports to identify eligible patients, providing immediate assistance with medications and transportation, and ongoing case management to ensure patients stay on track with their care. As Ashley puts it, the team acts as a crucial "middleman," bridging gaps between hospital care and outpatient follow-ups, ensuring nothing falls through the cracks.

Ashley’s role involves meeting patients in emergency situations, conducting detailed assessments, and connecting them with the necessary resources. She emphasizes the importance of patient involvement: "It may look like something small at the beginning, but the goal is to take the patient and work on the goals that they have, but also educate them on their health care." This holistic approach aims to empower patients to manage their health more effectively and ultimately achieve better outcomes. Her dedication to her role is evident in her deep commitment to patient care and her proactive approach to addressing both medical and social needs. Her journey from recognizing gaps in discharge planning to Regional One Health underscores her passion and the profound impact of her work.

Reflecting on the broader implications of this work, this complex care program, and this team, Susan summed it up nicely by saying, “If you can improve the health of the individuals, you can improve the health of the community.”

Health and Self-Sufficiency Outcomes:

• 70% enrollees are now food secure
• 169 jobs secured
• 14,224 rides provided/96% with stable transportation options
• 8,413 medically tailored home-delivered meals
• 77% of individuals with an open behavioral health domain connected to services
• 100% connected to a primary care home
• 58.5% of uninsured now have benefits
• 61% with an open housing/not permanent domain, now with stable housing
• (61% success rate in establishing permanent housing when there was none?)
• 25,931 prescriptions filled at Regional One Health outpatient pharmacies

Utilizations and Financial Outcomes:

• 32% reduction in emergency department visits (active enrollees)
• 121% increase in outpatient primary care and specialty visits
• 53% reduction in inpatient admissions (active enrollees)
• 1.71 days removed from the average length of stay in the acute care department, resulting in a      5,699-day total reduction
• 34.1% reduction in total cost of care
• 45.2% reduction in variable costs of care

Are you interested in the call to go above and beyond for underserved patients like these? The ONE Health program is supported by donors like you. Your generosity is crucial in enabling us to continue serving our community and transforming lives. Together, we can empower individuals and build a healthier, more resilient community.

Our mission at Regional One Health Foundation is to advance medical excellence and realize a bright future for health care in Memphis and across a five-state region. Our Foundation raises funds to support special, nonoperational projects throughout the entire Regional One Health system. Your gift brings hope and healing to thousands of patients in our community by helping us purchase state-of-the-art medical technology, provide advanced medical training for our caregivers, and initiate programs like ONE Health to combat various community health issues.

Together, we are a Foundation like no other in support of a program like no other.