Regional One Health's ONE Health Initiative

Tennessee

ONE Health is a complex care initiative designed to help chronically ill uninsured patients navigate the health system and access services to address their health-related social needs. The program employs nurses and social workers, who help patients pick domains where they need support, such as housing, transportation, insurance, employment, primary care, etc. Each domain is connected to service providers: the Memphis Area Transit Authority, federal insurance and housing programs, food stamp offices at churches and other social service organizations. Participants also have access to a once-a-week food pantry and information on various topics, including medication assistance, support-group classes and pain management. Additionally, Regional One Health provides financial assistance to help people afford insurance copayments and medications and connects them with primary care.

Partner Organizations

• Assisi Foundation of Memphis
• Camden Coalition
• Alliance Healthcare Services (a safety net mental health provider)
• Approximately 250 community groups across the region

Target Population

Memphis-area residents who are uninsured and have had four or more hospital stays or 10 or more emergency department visits in two years.

Care Team

Nurse, social worker, social service representatives

Timeframe

2018 - present

Results/ Studies

ONE Health served 101 people from April - December of 2018. Seventy-six participants remain active as of December 2018 and 25 people had graduated from the program.

Among the graduates, ONE Health observed a decrease of 95.6 percent in costs, 97.1 percent decrease in inpatient days and a 92.8 percent decrease in admissions. For all 101 patients, ONE Health avoided an extimated $1.75 million in costs, 69 inpatient admissions, 756  inpatient days and 156 emergency department visits.

Funding

Health system; private donations

Resources

Health Affairs article (September 2019)

ONE Health blog post (December 2018)