Trust: An Essential Ingredient for Transforming Health

Teachers, managers, and leaders know from experience that it is very difficult to get a person to do something they don’t think is valuable, even if it’s good for them. 

Telling someone what they “should do” may work in the short term (perhaps not even then), but it won’t stick – not even when the advice is well-meaning and would create better health for the person getting it.

Why? First, because there is a missing ingredient – trust. Second, when a person’s or patient’s daily life is full of obstacles, aggravations and disappointment, they don’t feel hopeful about the future. So they are less likely to follow guidance from a person who may have no understanding of the barriers they deal with every single day.

Trust takes time, and it takes an ongoing relationship, not a transaction.

‌Groundbreaking evidence from a recent University Hospitals pilot study of Medicaid patients shows how this applies to healthcare, especially when patients have complex health difficulties exacerbated by social determinants of health. These include poverty, a lack of safe housing and reliable transportation, and no access to fresh, healthy food, to name just a few. 

But there is very good news from that study: trust can be developed, but it requires a markedly different approach from caregivers. In the end, this also significantly reduces the patient’s medical expenses.

UH takes a serious interest not only in the health of our patients, but also in the health of those who live in the communities around us. Our Community Health Investment Report shows the many ways we work to improve our local population’s health and quality of life. 

For example, Patrick Runnels, MD, UH Chief Medical Officer of Population Health, obtained a $300,000 grant from the Robert Wood Johnson Foundation to help launch the “Web of Well-being” program and served as principal investigator. In the pilot project, which enrolled 88 patients, the team explored whether or not a relationship-based approach to case management could improve physical and mental health for vulnerable patients on Medicaid.

The program enlisted case managers to build relationships with each patient assigned to their care, devoting several hours a month to that patient. To allow for that, the case manager’s load decreased from the more traditional 60 to 100 patients, to 30.

In contrast to the transactional approach that focuses on problem-solving, usually in one appointment, this model utilizes case managers who meet with patients in their homes, in hospitals, or who accompany them to various medical appointments and get to know them and the details about their lives.

Only after spending time and building trust do they begin focusing on educating the patient or signing them up for various services, such as food assistance. They might also help them manage their daily needs, such as accompanying them on trips to the grocery store or showing them how to cook healthier meals.

In the past, Dr. Runnels says, “We weren’t having success with these patients because of barriers. They didn’t have trust. They didn’t feel they belonged, or that they were worth saving. So transactional solutions didn't stick and they didn't change the coping behaviors they had developed to manage the distress.”

Those coping behaviors were unhealthy in the long term but helped them manage stress in the short term. For example, the short-term comfort of a favorite fast food meal might act as a balm for the relentless stress of being unable to pay bills.

To help them feel they were capable of making changes, people first needed to believe in themselves, which begins with a sense of belonging. Knowing that there was someone – the case worker – who truly cared about them and their welfare made the difference.

Without that foundation, it’s natural for people to focus only on the complications and crises in front of them and avoid thinking about the future.

Hope is in short supply.

Patients also believe that the professional providers offering them health guidance live in an entirely different world. How could they possibly understand? 

So trust is also in short supply.

And when a patient has several health conditions – perhaps diabetes and heart disease, in addition to depression or anxiety – research showed they also did not respond to the typical transactional relationship with a provider.

Traditionally, a physician might prescribe medications, provide educational material, and then send the person on his or her way, expecting they will follow the physician’s advice. This often did not work.

What does work is when the case manager – apprised of the patient’s medical needs and issues – gets to know a wary patient, by calling and visiting, with “respectful persistence.” They might accompany them to find childcare, a job, better housing, or to get the heat turned back on.

After weeks, months or even as long as a year, the trust is built. In the study, 87 out of 88 patients reported a positive turnaround to their situation.  Significantly, the medical expense per patient, per month decreased 14 percent for the patients in the pilot, while a similar patient group who did not use this approach had an 11 percent increase in monthly medical expenses. That translates to an estimated savings of $730 per patient, per month, or nearly $10,000 annually.

Expansion is underway and will continue throughout 2024. The Web of Well-being program, which now includes 124 participants, is extending beyond Medicaid patients to also enroll interested Medicare patients. The goal is to reach 500 patients by the end of 2024.

UH is recruiting more staff – particularly community health workers – to make this happen. Many of these new staff members will also be patient peers, meaning they have successfully dealt with similar conditions, whether a substance abuse disorder, mental health diagnosis, diabetes, and so on.

Medicaid stakeholders have taken note of this success: one managed care organization for Medicaid patients has signed a contract to invest nearly $500,000 for UH to expand this program.

Ideally, such an effective model of care will not be limited to UH, but may spread to health systems around the country.

The powerful change brought about by this study’s methods offers lessons for us all: it shows providers why simply giving a patient directives toward better health is often not sufficient, and it demonstrates why immediate patient trust is not a given.

Healing begins with empathy. A caregiver’s deeper understanding of the hurdles a patient faces in daily life leads to greater compassion.

And we know that for all patients, compassion – a UH hallmark – is a vital component of trust and care.

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