“[The patient] had severe congestive heart failure, chronic asthma, uncontrolled diabetes, hypothyroidism, gout, and a history of smoking and alcohol abuse. He weighed five hundred and sixty pounds. In the previous three years, he had spent as much time in hospitals as out.” – Atul Gawande, “The Hotspotters,” The New Yorker, January 24, 2011

In the pressing search for ways to improve the quality of health care while reducing overall costs, one aspect that has garnered much attention has been the identification of so-called “super-utilizers.” These are individuals whose complex health care needs and very frequent medical encounters – most often as Emergency Room visits or hospital admissions – generate the highest costs over an extended period of time. As profiled in Atul Gawande’s compelling 2011 article in The New Yorker, primary care physician Jeffrey Brenner went a giant step further in his ground-breaking work in Camden, New Jersey. He used sophisticated geographical information systems and access to hospital billing records to map out “hot spots” – localized clusters of super-utilizers. In this way, health care professionals in Camden have been able to focus their work with a new level of efficiency, by reaching out to these concentrated populations where they live, and providing integrated on-site care to help them avoid many preventable acute health crises. For this innovative work, Dr. Brenner was recently awarded a MacArthur Foundation Fellowship (often, referred to as a “Genius Grant”).

At Community Catalyst, our Voices for Better Health project is working to improve care for older adults and people with disabilities who have both Medicare and Medicaid. Many of these people fall into the category of super-utilizers and, therefore, integration and coordination of their care offers significant opportunities for providing improved medical care at reduced total cost.

A recent bulletin from the Center for Medicaid and CHIP Services (CMCS) offers advice to state Medicaid departments on creating new programs to improve care for super-utilizer populations. The advice is based on interviews with 10 programs and describes key policy decisions states and providers grappled with in their design and implementation processes. The bulletin also offers states helpful suggestions on funding these programs using a variety of existing Medicaid programs, as well as some new ACA-created opportunities, such as the Health Homes Options and the dual eligible demonstration projects.

The key first step for a state is identifying potential patients who are likely both to use high levels of costly, but preventable, services in the future and are capable of responding to an integrated care program. Then the state will need to invest significant resources up front to create the infrastructure, including establishing successful partnerships among payers and primary care providers. The structure of these partnerships can vary widely. Several state program models have established intensive services, separate from providers:

  1. Centralized: Vermont and CareOregon have used a model in which case managers or outreach workers employed or contracted by the state or the Medicaid managed care organization are embedded in primary care practices.
  2. Supportive Networks: North Carolina has case managers travel between primary care practices and build capacity within multiple practices in their network to address the needs of their highest utilizers.
  3. Community-Based Care Teams: In Maine, interdisciplinary teams including nurse care managers, social workers, and behavioral health workers based in communities, visit patients in their homes and community settings.

Other programs offer more comprehensive services housed within clinics that focus all of their attention and resources on high-utilizing patients. They have a very small panel of patients for whom they provide short-term interventions or permanently take over care.

  1. Short-Term Intervention in a Super-utilizer clinic: Spectrum Health in Michigan provides comprehensive medical, mental health, addiction treatment and social services for a limited duration. The clinic then sends patients back to their primary care provider and specialty care providers with individualized care plans.
  2. Permanent Ambulatory ICU: Hennepin Health in Minnesota takes over care of patients when their primary care providers agree that the patients have complex needs beyond the capacity of traditional primary care. The clinic has an interdisciplinary staff with extensive experience caring for medically and socially complex patients.

The promise of improving care for super-utilizers is great and the need is tremendous. With its latest bulletin, CMS offers a helpful roadmap for states interested in targeting this population. However, one highly valuable approach missing in the bulletin is an effort briefly cited in Dr. Gawande’s “Hotspotters” article: partnering with community groups. Our friends at PICO, a faith-based organizing network, are working in five “hotspots” across the country, organizing patients, lifting their voices and working with providers to design programs that genuinely reflect people’s needs and wishes. Indeed, these kinds of partnerships can provide an essential key to reaching the goals of well-designed super-utilizer programs: improving care by addressing both a patient’s medical and non-medical needs which result in improved health outcomes and reduced costs.  

“Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.” ― Atul Gawande, “Better: A Surgeon’s Notes on Performance”