The hope was that bringing many other services to people with high needs would stabilize their health problems. While the strategy has succeeded sometimes, it hasn't saved money.
Then, in early 2018, something clicked, and turned Moore around. Today, he's more than five-years sober with his own apartment, and he has only needed the ER a handful of times since 2020. He's active in his church and building new relationships with his family., a team of nurses, social workers and care coordinators for his transformation.
But breaking this expensive cycle — particularly for patients whose lives are complicated by social problems like poverty and homelessness — has proved much harder than many health care leaders had hoped. For example, a pair of influential studies published in 2020 and 2023 found that the Coalition's pioneering approach of marrying medical and social services failed to reduce either
"That 80th ER visit may be the moment at which the person feels like they can finally trust us, and they're ready to engage," says Amy Boutwell, president of, who heads the nonprofit Center for Health Care Strategies, which helps state Medicaid agencies implement new programs. Organizations have begun to tailor their playbooks so the person with uncontrolled schizophrenia and the person battling addiction receive different sets of services.
The Coalition's original model hinged on the theory that navigating people to existing resources like primary care clinics and shelters would be enough to improve a person's health and simultaneously drive down health spending., but fails to stabilize their lives enough to keep them out of the hospital. One reason: People frequently admitted to the hospital often have profound, urgent needs for an array of social services that outstrip local resources.