Caring for the Costliest Patients: Better Care, Better Settings

31 Jul 2014

By now, it is well known that “super-utilizers” account for only five percent of patients but accrue more than 60 percent of health care costs. These patients make frequent trips to hospital emergency rooms or have repeated inpatient hospital stays, resulting in costly health care, but not necessarily high-quality care.

Aligning Forces for Quality South Central Pennsylvania (AF4Q SCPA) began initial super-utilizer work with several area health systems and has achieved impressive results:

  • One health system identified 40 initial enrollees in its program. For these patients, average monthly hospital charges have decreased by 60 percent. Inpatient hospital admissions have declined by 74 percent.
  • Overall, AF4Q SCPA reports a 20 percent reduction in the number of ED visits since 2010, with a total savings of more than $14 million.


  • Clinics operate like patient-centered medical homes, with enhanced communication between patients and their health care team, better care coordination, the use of evidence-based practice, and the use of electronic health records to track patients.
  • Clinics use a model where patients stay within the current primary care physician structure but receive additional support. Support may come in the form of home visits, a social worker’s services, and connections to community resources—even assistance in finding affordable housing.

With support from West Michigan’s Alliance for Health, the Center for Integrative Medicine created a team-based approach staffed by a physician, mental health worker, researcher, and physician assistant that specifically treats patients with complex needs throughout the area.

  • In its first year, the Center took on 418 new patients. It saw a 25 percent reduction in hospital charges for these patients.
  • ED visits were reduced by 50 percent.


  • An integrated care team connected to key community services.
  • Combined with a bundled payment model.
  • Built health information infrastructure to facilitate inter-emergency department sharing about patients who visit multiple hospital system EDs.

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