New York Providers Target Emergency ‘Super Utilizers’ to Coordinate, Reduce Hospital Visits

Velasquez J
Publication Year: 2016
Patient Need Addressed: Care Coordination/Management
Population Focus: Complex care
Type of Literature: Grey


Insights Results

Overview of article

  • Community Partners of WNY, a Performing Provider System (PPS) in New York, has employed a system of follow-up calls to better coordinate patient care to reduce repeat visits for ailments that may not be truly urgent. The concept is to identify and content frequent ER visitors who are either on Medicaid or enrolled in a Medicaid HMO and match them with primary care providers or health homes to reduce future, avoidable hospital visits
  • Community Partners of WNY is 1 of 25 Performing Provider Systems in the state that pair physicians, hospitals and community-based organizations to implement the state’s Delivery System Reform Incentive Payment program. Community Partners of WNY, along with the other PPS, are selecting from a menu of public health projects to carry out the state’s $8 billion DSRIP program, whose goal is to reduce avoidable hospitalizations by 25% by 2020
  • At the Buffalo hospitals, Community Partners of WNY has brought in 6 so-called “health connection” employees whose job it is to make follow-up calls to patients and begin documenting whether those people have a primary care physician
  • Community Partners has also purchased an app that is designed for us to be able to really capture patient interactions and to give a listing of who they interacted with in the emergency department. The data that’s collected will help the PPS gauge what sort of barriers are preventing super-utilizers from getting preventative care
  • Community Partners also plans to hire 4 emergency department navigators who will work face-to-face with patients from its largest emergency departments
  • The idea behind this approach is that this will be an iterative process, but the organization is optimistic that this work is an important start