A Patient-Centered Plan to Help Super-Utilizers
According to the Robert Wood Johnson Foundation (RWJF), health care spending in the United States is unevenly distributed, with the sickest five percent of patients causing more than 60 percent of health care costs. These “super-utilizer” patients make frequent trips to hospital emergency rooms or have repeated inpatient hospital stays, resulting in costly health care.
Aligning Forces for Quality Humboldt County (Aligning Forces Humboldt) was among the recipients of a $200,000 grant for its Care Coordination for Emergency Department Super-Utilizer project. Humboldt County, CA, has a high rate of Emergency Department (ED) utilization. In January 2013, the only urgent care center in the county closed its doors, which will only add strain on the ED. The project combines the expertise of the established care coordination programs in its community, the Care Transitions Program (CTP) at St. Joseph Hospital and the Priority Care program at the Humboldt Del Norte IPA. The two programs use unique perspectives and methods to offer patients identified as super-utilizers of the ED a personalized, patient-centered care plan.
The first enrolled patient in the super-utilizer program had 21 visits to the ED and more than $80,000 in unreimbursed charges.
“These are people the health care system has given up on,” said Jeffrey Brenner, MD, founder and executive director of the Camden Coalition of Healthcare Providers. Brenner’s super-utilizer work was the basis for the $2.1 million RWJF grant awarded to six communities across the country.
With a more focused plan, the care plan for super-utilizers can be streamlined, lowering frustration for staff and enabling them to use their skills to help more patients.
To best use the services and expertise of both programs involved, a “warm hand-off” system from the CTP to the Priority Care (PC) program was developed. The coordination is carried out by a multi-disciplinary team (MDT) consisting of primary care providers, registered nurse (RN) care managers from CTP and PC, ED physicians and staff, quality improvement leaders from the community clinics, and various other health care professionals. This group meets regularly to discuss the enrolled patients and the current systems of care. A subset of this group meets weekly to huddle around specific patient care concerns and updates. In combination with the assistance of the MDT, a strengthened collaboration of the existing care coordination services bridges the gaps in care coordination in the community.
Melissa Jones, project director, Aligning Forces Humboldt, said the program aligns with the Institute for Healthcare Improvement’s (IHI) Triple Aim framework, which focuses on improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care. The effort focuses on five components: individuals and families redesign of primary care services and structures, population health management, cost control platform, and system integration and execution. According to the IHI, communities that attain the Triple Aim will have healthier populations, in part because of new designs that better identify problems and solutions further upstream and outside of acute health care. Patients can expect less complex and much more coordinated care, and the burden of illness will decrease.
The first enrolled patient in the super-utilizer program had 21 visits to the ED and more than $80,000 in unreimbursed charges. After enrolling in the super-utilizer project, the patient is regularly seeing a primary care provider and has been to the ED only seven times, with less than $1,000 in unreimbursed charges. In addition, before enrolling, the patient was at high risk for homelessness due to a pending eviction from a low-income senior living facility. The patient is now living with a daughter and has frequent visits with the RN care manager.
An’a Verdi, BSN, RN, PHN, with the Priority Care program, asked one of her patients if she could put into words how the super-utilizer program and the care coordination efforts provided have affected her life, she responded, “I think both of you, An’a Verdi and Chris West, saved my life.”
St. Joseph Hospital provided data on the top 50 ED users in 2011, categorized by diagnoses, PCP, gender, age, primary payer, total charges, time of admission, day of the week, and ZIP code. The hospital has been able to provide demographic and charge- and cost-related data for the CTP for both the base period and the project period. Using the data helped establish criteria for the profile of a super-utilizer. The project aims to have a 10 percent decrease in utilization—acute, urgent, and emergency—for both core and intensive transitional services. The goal for PC is a 10 percent reduction in costs. Both of these programs will provide insights and support so the super-utilizers programs can leverage the existing work toward AF4Q goals.
In addition to direct financial benefits, the AFH super-utilizer project anticipates an improved working environment for staff. With a more focused plan, the care plan for super-utilizers can be streamlined, lowering frustration for staff and enabling them to use their skills to help more patients. This can reduce staff turnover and in general improve the efficiency of the ED.