Interventions designed to address the health conditions of people with multiple needs have not demonstrated effectiveness in the longer term ( Ryan, Abrams, Doty, Shah, & Schneider, 2016). In the United States, 5% of the population are responsible for 50% of healthcare spending, of which 47% are C-US patients ( Hayes et al., 2016). This acknowledges that despite complex needs, many individuals are not served well by current configurations of healthcare services. We propose the term ‘Currently under-served individuals familiar with the healthcare system’ (short-form: C-US) to replace HNHC. However the term ‘high needs, high cost’, although commonly used, is deemed by the authors to be pejorative and unhelpful, inherently blaming people for their high needs and consequent high health costs. Further, these individuals' limited ability to pay for services where universal healthcare is not available often results in additional treatment costs being born by healthcare providers, which has stimulated ideas for inter-professional teams to design a community engagement model that reduces costs and embodies ‘person-centered and efficient care delivery’ ( Smeets, Kroese, Ruwaard, Hameleers, & Elissen, 2020). This results in difficulties in acquiring essential services, and consequently they are unable to obtain timely access to community-based treatment, may experience exacerbations in their health and disease conditions, and end up seeking emergency treatment ( Hamilton et al., 2016). These people are often overwhelmed by the number of tasks to be undertaken or appointments needed as well as the complexity in choosing between competing needs to manage their health ( Rifkin, 2009). The high needs often result in high costs due to the way in which health care ecosystems are set up, meaning effective engagement and treatment is difficult. ‘High-need, high-cost (HNHC) patients’ is a term that has been used by healthcare systems for many years to describe individual consumers who have multiple chronic health conditions and functional limitations inhibiting their daily activities ( Hayes et al., 2016). Many people with complex health and mental health needs are not served well within our current health service configuration. Notably, the transfer of autonomy and power over health decision-making processes is emphasized, which will require revolutionary thinking about how healthcare is delivered for patients. The resulting model schematically posits a set of relational factors identified to be important in the establishment of CEH. These articles were used to refine further iterations of the model and included in the review where appropriate. A further 16 peer-reviewed articles were identified and were independently reviewed and quality rated. A model describing the processes underpinning CEH was then iteratively generated, resulting in additional terms that were used in a second review of the literature. This yielded ten papers that were reviewed by at least two authors and rated in terms of quality. A realist review was conducted to identify the existing literature around CEH. Community-Engaged Healthcare (CEH) is an approach that equips members of the community to levy power to advocate for their own health or social solutions, designing their own interventions to address needs with support from health providers. For many traditional health solutions may not address the fundamental issues confronting their health. This population is often referred to as ‘high needs, high cost’ (HNHC), a term that has been applied to refer to people who repeatedly utilize services without significant benefit (we have replaced this term with ‘currently under-served’ C-US). Poverty, health ecosystems, mental health, and community amenities are some of the issues confronting those who are not able to access appropriate support. In the US, many people are excluded from healthcare structures and systems, due to multiple macro and micro factors.
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