Adventist Health Clear Lake is located in one of the poorest counties in California, with health rankings in the lowest decile of the state. Fire devastation, lack of affordable housing, modest employment opportunities, and widespread addiction have stretched the limited resources of the response system in this rural community. An innovative, cross-sector, interprofessional collaborative was formed to address the needs of community members who were high utilizers of the police, emergency, criminal justice, and healthcare systems.
The collaborative approach was associated with a 44% reduction in hospital utilization, an 83% reduction in community response system usage, and a 71% reduction in costs for the population. Cross-sector, interprofessional collaboration between community agencies that share a select group of community members is an effective way to stabilize care, decrease healthcare and community system overutilization, improve care delivery, and reduce the costs of associated care.

The objective of this article is to describe Project Restoration's approach to cross-sector collaboration with a shared population of high utilizing community members, describe the process and outcomes of the collaboration, provide strategies to mitigate challenges that arise during collaboration and offer insights to inform similar initiatives in communities nationwide.

Hospitals across the region are assessing ways to establish a centralized infrastructure to collaboratively address the complexities of individual cases, as well as a regional council to explore process improvements to enhance the lives of vulnerable populations.

Total gross hospital charges in the population decreased $502,119 in the 6–12 months after the intervention, representing a 45% reduction in gross hospital charges. Similarly, total costs in the community response system decreased $220,303 in the 6–12 months after the intervention, representing an 84% reduction in costs to the community. The increased connection to primary care resulted in an increase in primary care fee for- service revenue of $51,678, representing an improvement of 168% to the health system. In addition, roughly a third of the patient population served is in a capitated agreement with a payer. Improved outcomes resulted in a $982,680 reduction in deductions from capitation surplus, or a 49% improvement in capitation financial performance.