SCPA: Challenging Fragmented Care

Certain patients present a health care conundrum. “Super-utilizers” account for only five percent of patients, but they 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 good-quality care. For example, one Pennsylvania woman had more than 50 CAT scans within a short span of time at various area hospitals. Super-utilizers often have multiple chronic medical conditions and social complexities that make their care difficult in a fragmented care setting.

Aligning Forces for Quality South Central Pennsylvania (AF4Q SCPA) wanted better for their patients. Clearly, emergency room visits for acute episodes would not address the larger issues that repeat visitors face. By enhancing primary care, emergency room overuse will decrease, and along with it, costs. AF4Q SCPA also aims to improve the quality of care and reduce re-hospitalizations.

The Alliance kicked off its super-utilizer program in February 2013, with interest from the Pennsylvania Department of Public Works and the Pennsylvania Department of Health. The High Utilizer Collaborative includes WellSpan Medical Group, Lancaster General Health, Pinnacle Health, Crozier Keystone, and Lehigh Valley Health Network, all committed to a two-year learning collaborative.

Since beginning the super-utilizer initiative, Wellspan Medical Group has enrolled 40 patients. For these 40 patients, average monthly hospital charges have decreased by 60 percent. Inpatient event frequencies have decreased by 74 percent.

The clinics in Pennsylvania vary in the model of care they deliver; some are more like patient-centered medical homes, while some are using 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. Says Samantha Obeck of AF4Q SCPA, “What they have in common is they all have a caring and supportive practice team.”

The collaborative is already transforming the lives of patients with complex problems. As one patient put it, “My team is awesome. From my first day in there, they have been friendly and compassionate—willing to do whatever it takes to make me feel better. We’re taking it one step at a time to bring me back to where I can lead a good lifestyle.”

Local nursing students and faculty have joined in the effort to support super-utilizers as well. York College of Pennsylvania’s nursing department operates several nurse-managed centers where wellness services are provided to economically disadvantaged and medically underserved residents. Nurse case managers at WellSpan are notified when a super-utilizer patient visits a wellness center with an eye toward good hand-offs in care and compiling complete medical histories. The WellSpan collaborative has expanded its partnership with the nurse-managed centers to provide additional in-home assessment for super-utilizer patients. Cheryl Thompson, RN, DNP, professor of nursing, described the additional impact these senior-level students, who are completing clinical course requirements, can have. “The students can spend as much time as they need working with these patients and see the same patient throughout an entire semester. We can fill in missing pieces.”

Now, a lay leader curriculum to engage local communities is under development, as is a faith-based plan and other patient engagement tools. AF4Q SCPA also is working with state representatives to access Medicaid data to inform its super-utilizer efforts further.
In the end, people with the most complex health care needs will be getting better, more consistent, and less costly care outside of the emergency room. Said one patient, “I feel like a new person because I’m not sick.”