How We Promoted Sustainable Super-Utilizer Care through Teamwork and Taking Time to Listen

Insights Results

Overview of article

• This article provides an overview of the facilitators and barriers to success for the development of the Care One Clinic, a multidisciplinary clinic that addressed the unique needs of super-utilizing, high-cost patients. This was funded through a grant from the CMS Low Income Pool to UF Health
• The goal of the program was to improve coordination and quality of care for super-utilizer patients (i.e., patients who visit the ED frequently or patients who have complex post-charge needs in a financially sustainable manner. The clinic is staffed at any given time by a social worker, hospitalist, addiction psychiatrist, clinical pharmacist and a nurse
  Methods
• Between November 2012 and October 2014, the study enrolled 635 patients: 186 super-utilizer and 449 post-discharge patients. 93% of patients had a mental health diagnosis and 66% had a substance use disorder

Results

• The program invited 2 categories of patients to the clinic: 1) Patients who were discharged from the hospital with more than ED visits in the prior 6 months; and 2) Uninsured/underinsured patients with complex-post discharge needs. The clinic served as an “ambulatory intensive care unit”, closely monitoring patients with a plan for eventual graduation to a local primary care clinic. Upon each patient’s initial visit, a social worker completed a needs assessment that identified barriers to care related to housing or transportation, and screened for substance abuse, depression, low health literacy and insurance eligibility. Then, a clinical pharmacist reconciled medications, provided patient education, monitored opioids use when needed and determined affordability of medications. Finally, a hospitalist and an addiction psychiatrist optimized medical management of chronic medical conditions, addressed untreated mental illness, substance abuse and pain and provided subspecialty referrals
• The clinic was open 5 half-days per week. Scheduling was planned with the expectation of a 50% no-show rate and a goal to see 5 patients per half-day. These targets were largely met
• The clinic sought to see frequent ED goers for at least 3-5 visits to identify and address the reasons for their repetitive emergency department use. They sought to move post-discharge patients to appropriate primary care providers as quickly as possible though uninsured patients usually remained in the clinic until they obtained public funding
• Overall, the clinic saw an overall 25% reduction in super-utilizer hospitalizations and a reduction in uninsured hospital admissions that covered the cost of the clinic
• The clinic found that the most effective way to reduce super-utilizing behavior was to identify what factors in a patient’s life may be contributing to that behavior and find ways to address them. This identification was in part to offering the staff the opportunity to sit quietly and listen, away from the distraction of the ED or inpatient unit. They discovered that some of the patients could not read, they lacked transportation, had uncontrolled pain, or were depressed or lonely. These were matters that patients did not easily disclose, but once the clinic fully understood them, they could begin to design care plans that actually worked
• Often, the clinic could not impact compliance with medications until social factors were addressed. Drilling down to the source of the problem was the key for several patients
• The clinic suggests the first step beginning to develop a program that targets understanding the needs of super-utilizers is to identify them and then analyze their demographics and medical profiles to define the scope of the problem. Then, clinics should pick an appropriate care team for the needs of the group, assign appropriate space and create a schedule that allows time to learn about and address patients’ medical and social barriers to care

Key takeaways/implications

• There are 2 main takeaways: 1) A multidisciplinary approach involving treatment of pain, mental illness and substance abuse along with adequate time to listen to patients and earn their trust are key ingredients to successful super-utilizer care; and 2) It’s important to build a financial case to justify the cost of this additional super-utilizer care. In this case, the reduction in uninsured inpatient days permitted additional insured admissions to generate revenues that exceeded the cost of the clinic. Other justifications might include reduced admissions, or reduced drug costs. Such care might also help providers achieve quality and continuity of care targets under certain value-based care arrangements
• Overall, the lessons learned were that chronic pain and addiction were significant drivers of ED visits in the health system, so it was important to provide on-site pain and addiction services. However, they did have to identify patients’ underlying issues in order to create sustainable interventions
• Challenges to implementation include: 1) Persuading patients to come to the clinic because most did not respond to telephone contact; and 2) Addressing transportation because the study could not provide transportation vouchers as they had initially intended, however United Way was able to sponsor transportation for participants