WORKING WITH THE SUPER-UTILIZER POPULATION

 
 
WORKING WITH THE SUPER-UTILIZER POPULATION
WORKING WITH THE
                                           SUPER-UTILIZER POPULATION:
                                           THE EXPERIENCE AND RECOMMENDATIONS



South Central Pennsylvania High Utilizer
                                           OF FIVE PENNSYLVANIA PROGRAMS
                                                    Crozer-Keystone Health System
                                                    William Warning, II, M.D.
                                                    Lancaster General Health
                                                    John Wood, M.D.
                                                    Neighborhood Health Centers
                                                    of the Lehigh Valley
                                                    Abby Letcher, M.D.
                                                    PinnacleHealth System
                                                    Nadine Srouji, M.D.
                                                    WellSpan Health
                                                    Chris Echterling, M.D.
                                                    Widener University
                                                    Caryl Carpenter, M.P.H., Ph.D.
WORKING WITH THE SUPER-UTILIZER POPULATION
WORKING WITH THE
SUPER-UTILIZER POPULATION:
    THE EXPERIENCE AND
 RECOMMENDATIONS OF FIVE
  PENNSYLVANIA PROGRAMS
    ____________________

        Crozer-Keystone Health System
               William Warning, II, M.D.


           Lancaster General Health
                   John Wood, M.D.


Neighborhood Health Centers of the Lehigh Valley
                  Abby Letcher, M.D.


            PinnacleHealth System
                 Nadine Srouji, M.D.


                WellSpan Health
                Chris Echterling, M.D.


              Widener University
             Caryl Carpenter, M.P.H., Ph.D.
WORKING WITH THE SUPER-UTILIZER POPULATION
FORWARD
The U.S. health care system is in a dizzying state of change. Those of us who work in the system can become
discouraged about our ability to achieve better health for our individual patients and our communities.
In this report, the members of the South-Central Pennsylvania High-Utilizer Learning Collaborative share our
experience working to achieve this goal. We hope you’ll find our experiences encouraging, even though we
have not found all the answers. We have learned that if health care providers have the courage to be creative
and open to change, a dedicated inter-disciplinary team that focuses on meeting all of their patients’ needs –
not just their medical needs – can improve quality of care while reducing health care spending. The lessons
learned working with this population can bolster the transformation of the entire health care delivery system.

We have shared details about the structure, processes, and outcomes of the programs in the Collaborative.
You will learn that there is no single model for working with super-utilizers, but we hope our experiences will
be helpful to those interested in the policy implications of focusing on the highest needs, highest cost patients.
We also hope to provide a framework for those who decide to start a super-utilizer program. Drawing on our
diverse experiences, we have proposed a set of Potential Program Benefits and Core Program Elements that
may be useful to providers and policy makers interested in this work. For public and private payers, as well as
potential program sponsors, we have outlined a set of Policy Recommendations that will support super-utilizer
programs and this transformational work.

ACKNOWLEDGEMENTS                               ●    Aligning Forces for Quality and       ●    Our sponsoring health systems
                                                    particularly Samantha Obeck,               and federally qualified health
Our super-utilizer teams are successful             DNP, RN and Chris Amy, who                 centers that took the risk to
because they are inter-disciplinary,                provided the infrastructure for            support our programs.
collaborative, creative, and visionary.             the Collaborative and funding.
We aim to always put patients at the                                                      ●    Our dedicated staffs for
center of what we do. Our work has             ●    The Family Medicine Educational            throwing themselves into this
been made possible by many others                   Consortium for being the birth             effort to serve our patients.
we wish to acknowledge here.                        place of this movement and for
                                                                                          ●    Our growing group of partners
Without them, this report, and the                  originally bringing us together.
                                                                                               – social service providers,
programs it highlights, would not              ●    Ellen Smith, M.D. (FMEC),                  community members,
have been possible.                                 Uchenna Emeche, M.D.                       government officials - who see,
    ●    The Highmark Foundation for                (Super-Utilizer Fellow),                   with us, a new way forward and
         funding our South Central                  Wendell Kellum, M.D.                       are willing to take the risk to
         Pennsylvania High- Utilizer                (Super-Utilizer Fellow),                   seize this opportunity.
         Learning Collaborative and                 Barry Jacobs, Psy.D (Crozer-
         this report. The Highmark                  Keystone) ), Kimberly Bahata,
         Foundation provided funding                MBA, RN, CPHQ (Lancaster
         to support learnings and                   General).
         sharing of best practices,            ●    Jeff Brenner, M.D. and the many
         patient data, and cost savings             dedicated members of the
         among Super Utilizer                       Camden Coalition of Healthcare
         programs in Pennsylvania.                  Providers who have been our
         Funding for direct care to                 mentors in this work.
         patients was not provided by
         the Highmark Foundation.



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WORKING WITH THE SUPER-UTILIZER POPULATION
6/25/2014
     6/25/2014


     The
      h United
     The Uniited States
                 States is
                        is approaching
                           approaching a critical
                                          criitical time
                                                    time off change
                                                             cha
                                                              h nge for
                                                                     for healthcare.
                                                                         he
                                                                         h althc
                                                                              h are. Th rising
                                                                                      he
                                                                                     The  riising cost
                                                                                                  cos
                                                                                                   o t and
                                                                                                       and
                                                                                                         d
     unacceptabl
               b y poor outcomes
     unacceptably        outcomes off our
                                       our he
                                           hhealthcare
                                              althcare system
                                                        system are
                                                                 are unsustainable.
                                                                     unsus
                                                                        u tainable. WWee must
                                                                                         must change
                                                                                                change
                                                                                                   n to to
     produce high-value
     produce  high-value ccare
                           are – better outcomes
                                 better outcomes at at lower
                                                       lower cost.
                                                              cost.

     One sstrategic
     One    trategi
                  g c way
                      way to
                           to approach
                              approach the
                                         the needed
                                             neeeded system
                                                       system change
                                                              change is
                                                                      is to
                                                                         to give
                                                                             give priority
                                                                                  priority attention
                                                                                           attention to
                                                                                                      to the
                                                                                                         the
     highest utilizing
     highest   utilizing patients.
                         patients. T hese “Super-utilizer”
                                   These   “Supe
                                              u r-utilizer” patients
                                                              patients not only
                                                                            only account
                                                                                 account for
                                                                                           for a disproportionate
                                                                                                 dispropportionate
     amount off medical
     amount        medical cost,
                            cost, but also
                                      also provide
                                           proovide high-yield
                                                     high-yield case
                                                                case studies
                                                                      studiies for
                                                                               for understanding
                                                                                   understanding thethe weakness
                                                                                                        weakness
     off our ccurrent
               urrrent system,
                       system, particularly
                               particularly when
                                             when faced
                                                   ffaaced with
                                                           with complex
                                                                complex medical
                                                                          medical and
                                                                                    and psychosocial
                                                                                         psychosocial needs.
                                                                                                         needs.

     Innovativee, data-driven
     Innovative,   data-dri
                        d iven cclinical
                                  liniical redesign
                                           rede
                                              d sign that
                                                      tha
                                                       h t helps
                                                            h lps this
                                                            he    this segment
                                                                         segment off our patient
                                                                                         patient population
                                                                                                 popullation
                                                                                                          o will
                                                                                                              will
     give a rapid
     give   rapid return
                   return off investment
                              investment in  in terms
                                                 terms off cost
                                                           cost savings
                                                                savings andand will
                                                                               will produce
                                                                                    produce the
                                                                                             the learning
                                                                                                 learning about
                                                                                                            about
     system cchange
     system    haange and
                      and reorganization
                           reorganization that tha
                                                h t will
                                                    will benefit
                                                         benefit all
                                                                  all patients.
                                                                      patients. Our
                                                                                 Our healthcare
                                                                                      healthcare ssystem
                                                                                                   ystem
     desperately needs
     desperately   needs centers
                         centers off innovation
                                       innovation to to design,
                                                        design, test
                                                                 test and
                                                                       and validate
                                                                            validate new
                                                                                     new models
                                                                                          models toto address
                                                                                                      addreess our
     highest needs,
     highest  needs, highest
                      highest costs
                               costs patients.
                                       patients. W Wee also
                                                       also ne  ed a firm
                                                             need    ffiirm commitment
                                                                            com
                                                                              mmitment to to collaboration
                                                                                             collaborationn and
                                                                                                             and
     shared llearning
     shared   earni
                 r ng so
                       so that
                          that successful
                                successful innovations
                                              innnovations can
                                                             can be disseminated
                                                                     disseminan ted as
                                                                                     as rapidly
                                                                                        rapidly and
                                                                                                and broadly
                                                                                                     broadl
                                                                                                         d y as
                                                                                                              as
     possible.
     possible.

     The work
     The  work of
                of tthe
                     he Aligning
                        Aligning Forces
                                   Forces for
                                            forr Quality
                                                 Quality South
                                                           South Central
                                                                  Central Pennsylvania
                                                                           Pennsylvania High-Utilizer
                                                                                           High-Utilizer Learning
                                                                                                            Learning
     Collaborative, presented
     Collaborative,   presented inin the
                                     the pages
                                         pages that
                                                 that follow,
                                                      ffol
                                                        ollow, embody
                                                                embody these
                                                                          these essential
                                                                                 essential elements
                                                                                           elements off innovation
                                                                                                         innova
                                                                                                          n     tion
     and sshared
     and   hared learning.
                 learning. In addition
                                 addition to
                                           to presenting
                                              p senting the
                                              pre            the work
                                                                 work off the
                                                                          the collaborative
                                                                               collaborative members,
                                                                                              members, this
                                                                                                          thi
                                                                                                           h s paper
                                                                                                               paper
     demonstrates clearly
     demonstrates    clearly the
                              the need
                                  need for
                                        for institutions,
                                            insstitutions, insurance
                                                            insurance payers
                                                                       payersr and
                                                                                and government
                                                                                     government toto create
                                                                                                     create
     environments that
     environments    that foster
                          ffos
                            oster this
                                  this discipline
                                       discipline off data-driven
                                                       data-driven aattention
                                                                      ttentionn to
                                                                                to the
                                                                                   the outliers
                                                                                       outliers with
                                                                                                with eeffective
                                                                                                       ffective
     engagement
     engagementn and
                   and redesign
                        redesign off our clinical
                                           clini
                                              n cal processes
                                                     processes toto improve
                                                                    improve care
                                                                               care and
                                                                                    and reduce
                                                                                        reduce cost.
                                                                                                cost.

     Pennsylvani n a’s state
     Pennsylvania’s    state government
                             government is   is currently
                                                 currently in
                                                           in a key
                                                                key position
                                                                    positionn to
                                                                              to support
                                                                                 support this
                                                                                          this work
                                                                                               work and
                                                                                                    and become
                                                                                                        become a
     national leader
     national  leader on the
                           the front
                               frontt lines
                                      lines off healthcare
                                                 h althcare reform
                                                 he         reform for
                                                                    for our m  ost costly
                                                                             most  costly and
                                                                                          and vulnerable
                                                                                               vulnerable patients.
                                                                                                          patients.
     I urge tthe
              he State
                 State off Pennsylvania
                           Pennsylvania to  to embrace
                                                embrace and
                                                         and expand
                                                              expand the
                                                                      the ‘super-utilizer’
                                                                          ‘supe
                                                                             u r-utilizer’ model
                                                                                            model and
                                                                                                   and utilize
                                                                                                       ut
                                                                                                       u ilize the
                                                                                                               the
     recommendations contained
     recommendations       contained in in this
                                           this white
                                                white paper.
                                                       paper.

     Sincerely
     Sincerely,



     Jeffrey Brenner, MD
     Executive Director
                                 are Providers
     Camden Coalition of Healthcare  Pro
                                       oviide
                                           d rs
                        th
          Coopeer S
     800 Cooper     t, 7 F
                  St,      Floor
                            loor
     Ca  mden, NJ
      Camden,  NJ 08102
     (609) 876-
           876-9549
                9549
     jjeff@camdenhealth.org
       eff@camde
               d nhealth.org
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3
__
WORKING WITH THE SUPER-UTILIZER POPULATION
A super-utilizer (SU) program is a data-driven, high-intensity, community-based,
patient-centered, inter-disciplinary team that engages SU patients to deliver
high-quality, comprehensive care, while simultaneously encouraging
self-advocacy and personal accountability.


EXECUTIVE                              high-quality, comprehensive care,        Some are homeless; many
                                       while simultaneously encouraging         experience social isolation in
SUMMARY                                self-advocacy and personal               sub-standard housing. Some
In October of 2012, the South          accountability.                          patients live in an environment of
Central Pennsylvania High-Utilizer                                              family and/or community violence.
                                       This report documents the
Learning Collaborative was                                                      Some are uninsured. However,
                                       experience of these five programs
established. The five members                                                   most are patients on Medicaid.
                                       and presents recommendations
of the Collaborative are                                                        Most lack the disposable income to
                                       based on that experience.
Pennsylvania programs in                                                        pay for medications or the co-pays
                                       It is intended to be useful for
York/Adams/Lancaster (WellSpan                                                  required by some payers, including
                                       organizations that want to
Health), Lancaster (Lancaster                                                   Medicare.
                                       develop a SU program, as well
General Health), Harrisburg                                                     (See Exhibits 3, 4, and 5.)
                                       as policy makers.
(PinnacleHealth System),
                                                                                System Failures: Although
Delaware County (Crozer-               Driving Diagnosis: A small
                                                                                many SU patients make
Keystone Health System), and           percent of patients consume a
                                                                                uninformed decisions about how
Allentown (Neighborhood                significant share of health resources
                                                                                and where to access the health
Health Centers                         nationally. This same skewed
                                                                                care system, most encounter a
of the Lehigh Valley)                  distribution of health care spending
                                                                                fragmented non-system with poor
that work with patients who are        has been documented in the
                                                                                coordination across providers –
frequent users of hospital services,   communities served by the SU
                                                                                medical, behavioral and social
both emergency department and          programs in the Collaborative.
                                                                                service providers.
inpatient. These programs were
                                       Who Are the Super-                       (See the patient stories throughout
inspired by the work of Dr. Jeffrey
                                       Utilizers?: The SU programs              that document how system failures
Brenner and the Camden Coalition
                                       use different criteria to define a       contribute to patients’ health
of Healthcare Providers in Camden,                                              problems.)
                                       super-utilizer. In general, they are
NJ, who have provided invaluable
                                       patients who have frequent and           Program Structure:
advice and support for the
                                       preventable hospital admissions          There is no single model for a SU
Collaborative’s efforts.
                                       and/or emergency department              program. The five programs in the
A super-utilizer (SU) program          (ED) visits. Typically, these patients   Collaborative vary in terms of
is a data-driven, high-intensity,      have multiple, chronic conditions        their structures and processes, but
community-based, patient-              such as diabetes, emphysema, and         they share the common goal of
centered, inter-disciplinary team      heart failure. Almost all have           working with SU patients to
that engages SU patients to deliver,   behavioral health co-morbidities.




                                                                                                                      __
                                                                                                                      4
                                                                                                                      __
WORKING WITH THE SUPER-UTILIZER POPULATION
improve the quality of care they         programs consider home visits to           162 and 56 patients, respectively,
     receive and their quality of life, and   be an essential component of SU            and have continued to grow.
     to reduce preventable utilization of     work. Home visits provide insights         (See Appendix 3 for most recent
     expensive inpatient and ED               to the patient’s living environment,       data from programs.)

     services. Four of the programs in        family and other social                    Three of the programs – Crozer,
     the Collaborative are based in           relationships, nutrition, and              LG Health, and WellSpan – have
     health systems; one is based in          medication management.                     been able to merge and analyze
     a neighborhood health center.            The programs consider in-person            their data. These three programs
     (See Appendix 1 for a detailed program   contact critical to establishing           combined served 138 patients as
     comparison of team composition,          strong relationships with patients
     community partnerships, and role in
                                                                                         of December 31, 2013, with
     patient care.)                           that can lead to improvement               significant growth in the programs
                                               in their health and well-being.           since that time. For these three
     Program Processes: The                   (See Appendix 1 for a comparison of        programs collectively, inpatient
     programs have different target           processes used by the SU programs. )
                                                                                         admissions dropped 34
     populations and different methods        (See Exhibit 11 for a list of assessment   percent after enrollment in
     of identifying and engaging their        instruments used by the programs to
                                              evaluate patients’ needs.)                 an SU program. In contrast,
     target populations, depending on
                                                                                         ED utilization increased after
     what data sources they can access.       Program Outcomes:                          enrollment. The programs believe
     Patients may be engaged during a         The SU programs in the                     that the reason for the increase
     hospital admission, in the ED, or in     Collaborative typically started            in ED utilization is that through
     a primary care practice. All of the      small and gradually expanded.              effective communication with
                                              The programs at Pinnacle and               the EDs, the patient is able to be
                                              Lehigh Valley have just begun              discharged from the ED, avoiding
                                               the data sharing portion of their         a much more costly inpatient
                                              work with preliminary results              admission (but resulting in an
                                              shown in the Appendix. As of               ED visit recorded as opposed
                                              December 31, 2013 they served              to an inpatient visit).
                                                                                         (See Exhibits 12 and 13 to see the
                                                                                         change in utilization after enrollment
                                                                                         in the SU programs.)




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5
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WORKING WITH THE SUPER-UTILIZER POPULATION
Home visits provide insights to the patient’s living
environment, family and other social relationships,
nutrition, and medication management.



If the average Medicaid                  Common Challenges:                        data allow programs to 1) identify
expenditure per hospital admission       Although the programs in the              potential SU patients and map their
is approximately $75001, then a          Collaborative use a variety of            location geographically, 2) design
34 percent reduction in admissions       models for providing services to          programs that meet the needs of
for these patients would equal           SU patients, the programs face            the identified population, including
$1,242,000 in estimated savings          similar challenges, specifically with     team composition, care processes,
to Medicaid for 138 patients over        data, patient engagement, care            and community partnerships, 3)
12 months. If the average                coordination, and funding. Of             develop program evaluation
expenditure per ED visit, not            these, access to data is one of           measures, and 4) plan for the
resulting in a hospital admission,       the most important. A robust              impact of SU work on the health
for adults 18-64 years of age is                                                   system sponsors such as workforce
                                         healthcare data stream is critical
                                                                                   redeployment.
approximately $10972, then a 12           to SU programs. Timely,
                                                                                   (See Exhibit 16 for a case example
percent increase in ED visits would      comprehensive and accurate                from Lancaster General Health.)
equal $54,498.96 additional              utilization, claims and cost-related
estimated expenditures over 12
months. The net effect would be an
estimated savings of $1,187,501.04
for 138 patients over 12 months.
(See Exhibits 14 for estimated pre and
post enrollment expenditures).
Of the 138 patients presented in
                                                     RECOMMENDATIONS:
these exhibits, 33 percent are no               Commonwealth of Pennsylvania: Provide state support
                                                for the development of health information exchanges
longer enrolled in the programs.
                                                that deliver real-time, all-payer data to programs on a daily
The vast majority (68 percent)                  basis, including utilization data from all hospitals. (A crucial
successfully “graduated” from the               interim step would be to facilitate access for super-utilizer
program and returned to a primary               programs to Medicaid data including medical, behavioral
care provider for on-going care.                and substance abuse data from all sources at the state level.)
Some patients died (14 percent); a
                                                Public and Private Payers: Use alternative payment
small percent dropped out of the                mechanisms such as case management fees, per episode of
program or were lost to follow-up.              care payments, and shared savings contracts for SU
A very small number (4 percent)                 programs.
were asked to leave by the program
                                                Sponsoring or Partnering Health Systems: Provide
for failure to actively engage.                 access to 1) real-time utilization data for super-utilizer
(See Exhibit 15 – reasons for                   patients, and 2) current and historical charge, payment and
leaving program. )                              cost data for super-utilizer patients.




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WORKING WITH THE SUPER-UTILIZER POPULATION
THE DRIVING
                  INTRODUCTION                                              DIAGNOSIS
                                                                            The U.S. leads the world in health care
     In October of 2012, the South Central Pennsylvania High-Utilizer
     Learning Collaborative was established. The five members               expenditures per capita, roughly $8,995
     of the Collaborative are Pennsylvania programs in                      in 2012; health care in the U.S. consumes
     York/Adams/Lancaster (WellSpan Health), Lancaster                      the largest share of GDP of all nations in
     (Lancaster General Health), Harrisburg (PinnacleHealth                 the world.3 Researchers have known for
     System), Delaware County (Crozer-Keystone Health                       some time that the distribution of health
     System), and Allentown (Neighborhood Health Centers
                                                                            care expenditures is skewed, with a small
     of the Lehigh Valley). These programs work with patients
     who are frequent users of hospital services, both emergency            percent of the population consuming
     department and inpatient. These programs were                          a disproportionately high share of
     inspired by the work of Dr. Jeffrey Brenner and the Camden             resources. In 2010, the top 1 percent
     Coalition of Healthcare Providers in Camden, NJ, who have              (ranked by their health expenses)
     provided invaluable advice and support for the Collaborative’s         accounted for 21.4 percent of the $1.3
     efforts.
                                                                            trillion spent on health care in the U.S.
     The Collaborative is called the High-Utilizer Learning                 that year.4 Most are people with
     Collaborative. However, the programs in the Collaborative              multiple chronic conditions whose
     typically refer to their work as “super-utilizer” work. This term      annual expenses are roughly $88,000
     is used throughout the country. As Dr. Brenner has frequently          per person.
     noted, either term - “super-utilizer” or “high-utilizer” - is
     inherently misleading, as it suggests the problem of over-uti-         There are many factors that explain the
     lization lies entirely with patients. As the Camden Coalition and      rapid growth in total health care expen-
     the five programs in Pennsylvania have learned, over-utilization       ditures. Economists estimate that about
     often reflects failures within the health care delivery system.
                                                                            63 percent of spending growth is due to
     The Collaborative was created so that these super-utilizer             increases in utilization; the remaining 37
     (SU) programs could share best practices, patient data, and            percent is due to increases in prices.5
     cost-saving strategies. Lessons learned from the SU programs           The increase in utilization, in turn, is due
     could help to transform the health care delivery systems in            to 1) the aging of the U.S. population, 2)
     their communities. The Highmark Foundation funded the                  the growing prevalence of chronic
     Collaborative beginning in April, 2013, with the following
                                                                            diseases, 3) the development of new
     objectives: 1) to provide each regional health care provider with
     the tools to provide high quality, efficient care for high-utilizing   technologies and treatments, and 4)
     patients; 2) to realize cost savings through the SU programs;          unnecessary or preventable use of
     and 3) to serve as pilots for new payment mechanisms to                expensive services including inpatient
     support new care delivery models. Super-utilizer programs              hospital admissions and emergency
     provide intensive outpatient care coordination services to             department (ED) visits.
     patient populations with complex medical, behavioral, and
     social needs. This report examines the experience of the
     five super-utilizer programs in the Collaborative and
     recommends policies that could facilitate and extend the
     work with the SU population to other locations in Pennsylvania
     and around the country.




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WORKING WITH THE SUPER-UTILIZER POPULATION
The U.S. leads the world in health care expenditures per capita,
roughly $8,995 in 2012; health care in the U.S. consumes
the largest share of GDP of all nations in the world.3



Inappropriate use of hospital          receipts for hospital services.6        The Camden Coalition
services can be physician-and/or       The programs in the Collaborative       demonstrated that through
consumer-driven. Consumer-driven       have identified similar patterns in     intensive outpatient care
utilization of hospital services       their communities. In Lancaster,        coordination, it was possible to
can result from poor consumer          for example, only 3 percent of all      reduce expenditures while
decision-making about their health     Medicaid patients in the county         improving quality of care. “By
needs and/or system failures that      account for 51 percent of Medicaid      helping manage the physical,
make it difficult to utilize out-of-   spending. At WellSpan in York, 4        behavioral and social needs of these
hospital services. The SU programs     percent of patients represent about     individuals, the Coalition has been
focus on the consumer-driven           half of all expenditures. The patient   successful in breaking the harmful
overuse of hospital care and the       stories included throughout this        and costly cycle of inappropriate
system failures that contribute        report vividly illustrate how a small   emergency department (ED) or
to that overuse.                       number of patients can consume a        inpatient admissions.”7 This work
                                       large share of health spending in       inspired a number of communities
In their initial work with super-
                                       their communities.                      to develop SU programs of their
utilizing patients, the Camden
                                                                               own, including the communities
Coalition of Healthcare Providers      (See Exhibit 1, the story of Bill at
                                       PinnacleHealth, whose very high         that are part of the Collaborative.
found that 5 percent of hospital
                                       hospital utilization was reduced by
patients in Camden accounted           80 percent after enrolling in the SU
for more than 50 percent of all        program.)




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WORKING WITH THE SUPER-UTILIZER POPULATION
Most SU patients have multiple,
                                                                                     chronic conditions, including one
                                                                                     or more mental health or substance
                                          Each program has its own metric            abuse diagnoses. Some are
                                          for defining a “super-utilizer”, e.g. at   homeless; many experience
                                          Pinnacle a super-utilizer is defined       social isolation in sub-standard
                                          as an adult with 2 or more inpatient       housing. Some patients live in
                                          admissions OR 6 or more ED visits          an environment of family and/or
     WHO ARE THE                          in a 6-month period; whereas the           community violence. Others lack
     SUPER-UTILIZERS?                     program at Crozer has focused              the disposable income to pay
     The answer to this question varies   primarily on patients with 2 or more       for medications or the co-pays that
     by community. In general, SU         inpatient admissions in 6 months.          are required by payers, including
     patients are those who have                                                     Medicare.
                                          In Camden, most of the patients
     frequent and preventable hospital    who make high use of inpatient             (See Exhibit 2, the story of Carole at
     admissions and/or ED visits.                                                    WellSpan, as an example of a patient
                                          services are insured, often by             with significant emotional problems
                                          Medicare and/or Medicaid; whereas          that went unattended by her doctor
                                                                                     before enrollment in Bridges to Health
                                          those who utilize the ED frequently        and resulted in preventable hospital
                                          are more likely to be uninsured. The       admissions.)
                                          same is true for the patients served
                                                                                     As of December 31, 2013, three of
                                          by the Collaborative’s programs.
                                                                                     the programs (Crozer, LGHealth,
                                                                                     and WellSpan) had seen 138
                                                                                     patients, with an average age of
                                                                                     52.2 years. Exhibit 3 presents
                                                                                     the payer distribution for these




__
9
__
The patients cared for by the Collaborative’s programs experience
a fragmented health care system with poor coordination across
providers – medical, behavioral health, and social service providers.



patients. Some are uninsured; a           Preventable use of the hospital can     Consumer Decisions
large group are on Medicaid; and          be triggered by many breakdowns
                                                                                  Super-utilizer patients often make
many are dual eligibles, i.e. those       in this delivery system. For
                                                                                  uninformed decisions about their
with both Medicare and Medicaid.          example, in the Lehigh Valley
                                                                                  use of services because they lack an
                                          program, a patient on dialysis had a
Exhibit 4 lists the percent of the                                                understanding of 1) their illnesses,
                                          costly inpatient stay because the
138 SU patients with various                                                      2) the appropriate ways to manage
                                          community transportation service
diagnoses. Ninety percent have a                                                  their health, 3) the “language” the
                                          never picked him up for his regular
documented behavioral health                                                      system uses, and 4) how to navigate
                                          outpatient dialysis appointment. A
diagnosis, along with chronic                                                     the system to get the services they
                                          patient in Lancaster had inpatient
conditions such as diabetes and                                                   need. Often they have received
                                          stays due to a history of
emphysema. Exhibit 5 presents                                                     little or no explanation about their
                                          uncontrolled diabetes and
the social determinants of                                                        disease(s) or how to manage their
                                          childhood trauma that led to post-
utilization for these patients. Even                                              health outside of the hospital.
                                          traumatic stress disorder, which was
though most of these SU patients                                                  Those with multiple prescription
                                          never appropriately addressed by
have insurance, 90 percent of them                                                drugs can be confused about
                                          the delivery system outside the
list financial issues as a major life                                             which medication treats which
                                          hospital. A patient at Crozer with
stressor. Financial limitations result                                            illness or how their prescriptions
                                          complex medical problems was
in problems with housing,                                                         should be taken.
                                          discharged from a skilled nursing
transportation and food, all of
                                          facility to home with no record of      Even those who have a PCP may
which affect their health, and
                                          the medications prescribed at           bypass the PCP office and go to the
use of services.
                                          discharge, making it difficult to       ED because they aren’t able to
(See Exhibit 6, the story of Robert at
                                          manage her care as an outpatient.       schedule a timely appointment, are
LG Health, whose frequent hospital
admissions and ED visits were the                                                 unable to reach office staff, or
result of problems with housing,
                                          Many SU patients lack access to a
                                                                                  believe they will receive “better”
transportation and food insecurity.)      primary care provider (PCP),
                                                                                  and timelier care in the ED. Staff in
                                          particularly in cities like Camden
System Failures                                                                   the SU programs spend time
                                          and Chester (Crozer). Patients
                                                                                  teaching patients how to make and
The patients cared for by the             without insurance or with Medicaid
                                                                                  keep appointments with both
Collaborative’ s programs                 may have difficulty finding a PCP.
                                                                                  specialists and primary care
experience a fragmented health            Federally-qualified health centers
                                                                                  providers. Often staff accompany
care system with poor coordination        (FQHC) provide an important
                                                                                  patients to appointments to teach
across providers – medical,               safety-net but may lack the capacity
                                                                                  patients what questions to ask and
behavioral health, and social service     to meet all of the need for primary
                                                                                  how to advocate for themselves, or
providers. Exhibit 10 is a graphical      care services. Cultural and
                                                                                  to assure the patient understands
representation of the health and          language differences between
                                                                                  the provider’s treatment plan.
social service “systems” in Lancaster     patients and providers also serve as
County – the systems that SU              barriers to receiving the right care
patients find so difficult to navigate.   in the right place at the right time.




                                                                                                                          __
                                                                                                                          10
                                                                                                                          __
THE CAMDEN                               conditions that could be treated
                                              by a PCP outside the hospital 8
     COALITION                                Dr. Brenner further segmented the
     Starting in 2003, Dr. Jeffrey Brenner,   super-utilizer population to develop
     a family physician practicing in         different strategies for different
     Camden began to look at patterns         sub-sets of this population.
     of hospital use by Camden
                                              Dr. Brenner found that patients who
     residents, using a process dubbed
                                              were frequent users of inpatient
     “hotspotting.” The coalition he
                                              and ED services clustered in certain
     founded built a citywide database
                                              geographic locations. Two of the
     of claims data from the three local
                                              original hotspots were a high-rise
     hospitals. These data showed that
                                              residential complex for seniors and
     50 percent of Camden residents
                                              people with disabilities, and a
     visited a local ED or hospital in a
                                              nursing home with both skilled
     single year, twice the rate for the
                                              and long-term beds.
     U.S. overall. The majority of the
     inpatient or ED visits were for          The Camden Coalition of Health
                                              Care Providers is a not-for-profit
                                              collaborative of practitioners, health
                                              centers, and hospitals. The Coalition
                                              created a citywide care




__
11
__
Dr. Brenner found that patients who were
frequent users of inpatient and ED services
clustered in certain geographic locations.


management system with the              the development of personal            the SU program. The health
mission to improve the quality,         autonomy in the healthcare arena.      system-based SU programs also
capacity, and accessibility of the      As with the Camden Coalition,          are advocates within their own
health care system for vulnerable       the five SU programs of the            organizations for the delivery
populations in Camden. The              Collaborative have demonstrated        system transformations needed
Coalition now includes active           the potential of this approach         to meet the needs of the SU
participation from all three Camden     to offer outstanding care,             population.
hospitals, two Federally Qualified      meaningful patient engagement,
                                                                               One disadvantage of health system
Health Centers, private medical         and significant cost reduction.
                                                                               ownership of an SU program is
practices, and social service
                                        Appendix 1 is a chart that             that the program lacks access to
agencies serving Camden residents.
                                        compares the five programs on a        utilization data from other providers
The goal of the Coalition is for
                                        number of dimensions of structure,     in the region. SU patients often
Camden to be one of the first cities
                                        process and outcomes. As this          move around, visiting multiple
in the U.S. to dramatically bend the
                                        comparison clearly demonstrates,       hospitals for both inpatient and
cost curve while improving
                                        there is no single model for an SU     ED services. A health system SU
healthcare quality and access.
                                        program. The five programs in the      program may have difficulty
It is the work of Dr. Jeffrey Brenner   Collaborative vary in terms of their   developing a comprehensive
and the Camden Coalition that           structures and processes, but they     picture of a patient’s utilization
inspired the development of SU          share the common goal of working       patterns that includes providers
programs in the five health care        with SU patients to improve the        outside their system.
organizations that make up the          quality of care they receive and
                                                                               The fifth program, Lehigh Valley,
South Central Pennsylvania High-        their quality of life, and to reduce
                                                                               is based in a neighborhood health
Utilizer Learning Collaborative.        preventable utilization of expensive
                                                                               center. The Lehigh Valley program
                                        inpatient and ED services.
                                                                               is funded by a Center for Medicare
THE COLLABORATIVE                       Unlike many other SU programs          and Medicaid Innovation (CMMI)
- STRUCTURE                             around the country, four of the        grant administered by Rutgers
Program Location                        Collaborative programs are part        University in New Jersey. The
                                        of multi-hospital health systems       grantees in this program are more
A super-utilizer (SU) program           (Crozer-Keystone Health                community-based than the other
is a data-driven, high-intensity,       System, LG Health,                     programs in the Collaborative.
community-based, patient-               PinnacleHealth System, and             For example, all of the CMMI-funded
centered, inter-disciplinary team       WellSpan). These programs have         programs employ a community
that engages SU patients to deliver     the advantage of access to hospital    organizer to help community
high-quality, comprehensive care        utilization and cost data that would   members advocate for pragmatic
while simultaneously encouraging        not be readily available to programs   solutions to the gaps in health
self-advocacy and personal              operating outside a health system.     and social service systems.
accountability. The team assists        Hospital databases are used to
patients to navigate the health         identify potential participants in
care delivery system but also fosters




                                                                                                                       __
                                                                                                                       12
                                                                                                                       __
the life of an SU patient. The patient
                                                                                    has several medical issues and
                                                                                    lacks “mind” and “spirit” support.
                                                                                    The post-intervention map
     The Lehigh Valley program has          those who do not have a PCP. The        demonstrates an increase in the
     the most extensive community           program has a formal partnership        “mind” and “spirit” parts of the
     partnerships, both formal and          with the Community Exchange, a          patient’s life, and a complete
     informal, including partnerships       volunteer Time Bank. They are able      elimination of hospitalizations.
     with the faith-based community         to involve volunteers in the care
                                                                                    The primary disadvantage of the
     in their area. The advantage of        coordination process. They
                                                                                    Lehigh Valley program’s location is
     a community base is that               encourage SU patients to
                                                                                    their lack of access to hospital data.
     coordination with community            become volunteers themselves.
                                                                                    Although the program has informal
     agencies may be easier. In addition,   Participation in volunteer activities
                                                                                    affiliations with the hospitals in the
     operating out of a neighborhood        has been shown to improve
                                                                                    area, they have only begun receiving
     health center gives the program a      physical and mental health by
                                                                                    data from the hospitals about
     site to provide primary care for       reducing social isolation. Exhibit 7
                                                                                    admissions and ED visits. Therefore,
                                            presents two spaghetti maps, a
                                                                                    they have not yet begun mining the
                                            tool used by the Lehigh Valley
                                                                                    data to identify potential program
                                            program to help patients visualize
                                                                                    participants based on their
                                            a snapshot of their lives medically,
                                                                                    utilization patterns. Until recently,
                                            mentally, and spiritually. The
                                                                                    the program relied entirely on
                                            pre-intervention map shows
                                                                                    referrals to identify potential
                                            the tangled “spaghetti” that is
                                                                                    patients. The program has now
                                                                                    completed an agreement with a
                                                                                    large health system in the area to




__
13
__
All SU programs provide care coordination;
some also provide primary care services and are
termed “transitional PCP super-utilizer programs”.


provide data about inpatient and       features. One of the many benefits       and “graduating” them back
ED utilization that will allow the     of the Collaborative is the              to the practice’s Patient-Centered
program to start data-driven patient   shared learning from different           Medical Home (PCMH).
selection. They hope to develop        program models.
                                                                                Exhibit 8 presents a side-by-side
similar agreements with two
                                       Role of the SU Program                   comparison of PCMH and SU
other local health systems.
                                                                                programs. Although the two
                                       All SU programs provide care
The strong community base of                                                    concepts share some features,
                                       coordination; some also provide
the Lehigh Valley program may                                                   there are important distinctions.
                                       primary care services and are
produce a wider range of referrals                                              Care coordination is the focus of
                                       termed “transitional PCP super-
than those in the health system-                                                SU programs, rather than the direct
                                       utilizer programs”. The WellSpan
based programs, but it is harder                                                provision of medical care, even
                                       and LG Health programs assume
to apply the program’s inclusion                                                though some programs do provide
                                       the role of PCP on a temporary
and exclusion criteria to patients                                              primary care services. SU programs
                                       basis in the Bridges to Health
referred by other providers and                                                 are more proactive in engaging
                                       program and Care Connections
community groups. As a result,                                                  patients and have more resources
                                       clinic, respectively. In addition,
the program often works with                                                    directed at patient engagement.
                                       they provide intensive care
the extreme outliers in terms
                                       management services, coordinating        Pinnacle has three projects where
of medical and psychosocial
                                       specialty, mental health, and social     patients can receive care coordination
complexities and challenges.
                                       services. The programs’ goals are to     with or without primary care
Given limited resources, all SU
                                       stabilize patients’ health, coordinate   services. One is an internal medicine
programs need to prioritize cases
                                       other needed services, equip them        residency clinic; another is in the
to work with those patients who
                                       to navigate the system, and then         hospital emergency department;
are most likely to benefit from
                                       return them to their previous PCP.       and the third focuses on providing
intensive, outpatient care
                                       The Crozer program is located in         medical services and navigation for
coordination. This has not always
                                       the outpatient practice of the           patients in an independent living
been an option for the Lehigh
                                       health system’s family medicine          facility that was identified through
Valley program but should
                                       residency program, the Center for        hot-spotting.
improve with the new data
                                       Family Health in Springfield. Their
agreement.                                                                      The program in the Lehigh Valley
                                       target population is SU patients in
                                                                                is the most community-based
The other programs in the              that practice, so all patients have a
                                                                                program of the five. Primary care
Collaborative would like               resident or attending physician.
                                                                                is provided at the Neighborhood
to emulate the community               The SU team does not take over the
                                                                                Health Centers of the Lehigh
connections features of the            primary care role but does provide
                                                                                Valley clinic. Care coordination
Lehigh Valley program but lack         intensive care coordination
                                                                                is provided by a team, working
the time and resources to do so.       services, with the goal of patient
                                                                                with an extensive network of
As these programs expand, they         self-sufficiency, teaching them
                                                                                community partners.
hope to develop some of these          how to navigate the system,




                                                                                                                         __
                                                                                                                         14
                                                                                                                         __
The SU Team                           provide primary care services to
                                           SU patients; others have residents
     All the SU programs in the
                                           (usually family medicine) in the
     Collaborative use inter-
                                           direct-care role. All of the programs
     disciplinary teams. The composition
                                           have physician leaders who oversee
     of the SU team depends on
                                           enrollee care and medical
     the characteristics of the target
                                           management issues.
     population and the role of the
     SU program. The comparison            Nursing: Some of the Collaborative
     chart in Appendix 1 outlines          programs employ nurse (RN) case
     the staff composition of each         managers on a full or part-time
     program in the Collaborative.         basis to do medical needs
     The SU team may include:              assessment and, in some cases,
                                           oversee care coordination.
     Physician or Advanced
     Practice Nurse: Some programs         Pharmacy: All programs have
     have a physician or nurse             clinical pharmacists in a consulting
     practitioner working full-time to     role. Medication reconciliation is




__
15
__
The composition of the SU team depends on
the characteristics of the target population
and the role of the SU program.



a key function in SU programs.         nurses (LPNs), care navigators (this    Clinic. They have two partnerships
Medication reconciliation involves     term encompasses many workers           with community pharmacies for
comparing the medications listed       including, but not limited to, nurses   enhanced services, as well as a link
in the patient’s medical record        and emergency medical                   with the Lancaster Emergency
or discharge summary with the          technicians), community health          Management Service Agency
medications the patient actually       workers (a lay person trained to        which staffs two of their navigator
has and uses at home. The diff-        provide basic health education          positions. WellSpan partners
erence can be striking at times.       and care), or health coaches (usually   include Healthy York Network
Some programs also use clinical        lay persons trained in motivational     (a charity care program)
pharmacists and drug manage-           interviewing and goal setting           and Healthy York Pharmacy
ment programs to allow pharmacists     techniques).                            (a not-for-profit pharmacy).
to titrate medications.
                                       Finally, programs have consultation     All programs have developed
Behavioral Health: Most                relationships with dieticians,          informal arrangements with a
SU patients have at least one          diabetic educators, legal service       variety of health and social
behavioral health diagnosis            attorneys, clergy, and others.          service resources within their own
that requires either direct care                                               organizations (specialty services
                                       Partnerships
or consultation from a behavioral                                              within the health systems) and in
health specialist, such as a           No SU program has the resources         the community. Typically, these
psychologist or social worker.         to meet all of their patients’ needs,   include area agencies on aging,
These professionals do behavioral      therefore all SU programs               community mental health
health needs assessments and,          collaborate with a variety of           organizations, county social service
in some cases, provide counseling      community organizations through         agencies, and homeless shelters.
services to SU patients.               formal or informal partnerships.        The WellSpan and LG Health
                                       Formal partnerships in the Lehigh       programs have periodic community
Social Work: Several programs
                                       Valley program include the Parish       care coordination meetings, similar
have a full or part-time social
                                       Nursing Coalition, Community            to the community-wide case
worker to assist patients with their
                                       Exchange (volunteer Time Bank),         management conferences started
social service needs, including
                                       and Congregations United for            in Camden. Other Collaborative
housing, insurance and other
                                       Neighborhood Action (CUNA).             programs lack the staff to organize
benefit enrollment.
                                       The LG Health program has a             and manage this kind of arrange-
Community Health Worker:               formal agreement with the               ment, but all would like to develop
Programs employ a variety of           Lancaster County Human Services         a stronger community base for their
personnel to work with patients in     Office, and has a full-time, county-    programs in the future.
their homes and in the community.      supported social service liaison
These include licensed practical       working in their Care Connections




                                                                                                                      __
                                                                                                                      16
                                                                                                                      __
The Role of SU Programs                The residency-based Crozer              change management, population
     in Health Professions                  program partnered with the              health, as well as complex medical
     Education                              Camden Coalition to form a              management.
                                            Super-Utilizer Fellowship funded
     All of the Collaborative’s                                                     The advantage of residency
                                            by the Aetna Foundation. The first
     programs have affiliations with                                                affiliations is that physicians-in-
                                            two family medicine fellows started
     graduate medical education                                                     training (residents) may be available
                                            in the summer of 2012. A principal
     programs. In two programs                                                      to assume the PCP role for some SU
                                            goal of the fellowship is to train
     (Crozer and Pinnacle), the                                                     patients. In addition, students from
                                            physicians in the development
     residents may serve as the PCP                                                 social work, psychology, or pharmacy
                                            and management of SU programs.
     for SU patients. All programs are                                              are available to serve as active
                                            Fellows spend half their time in
     committed to educating current                                                 members of the SU team. Programs
                                            Camden, learning from the
     and future physicians, as well as                                              can make a significant contribution
                                            Coalition, and half their time at
     health system administrators, about                                            to health profession programs by
                                            Crozer developing their SU
     the SU population and their needs                                              exposing future physicians, nurses,
                                            program and working with SU
     through case conferences, formal                                               psychologists, pharmacists, and
                                            patients. Fellows are actively
     presentations, rotations, and                                                  social workers to the SU population
                                            involved in educating medical
     lectures. Some programs have                                                   and the system failures that are
                                            students, residents, and the hospital
     affiliations with other professional                                           barriers to effective patient care.
                                            system’s administrative and medical
     education programs, e.g. the York
                                            staff. Building on the Crozer           The disadvantage of residency
     College of Nursing and the
                                            experience, LG Health started a         affiliations is that resident physicians
     WellSpan program. Most
                                            Population Health Fellowship in         and other health professions
     programs have other health
                                            July, 2014 that will train family       students graduate, making
     professions students on the SU
                                            medicine residents in leadership,       continuity of relationships with
     team. The Crozer program, for
     example, has Master of Social Work
     and Doctor of Psychology students
     as active team members.




__
17
__
Programs can make a significant contribution to health profession programs
by exposing future physicians, nurses, psychologists, pharmacists, and social
workers to the SU population and the system failures that are barriers to
effective patient care.


patients more difficult. Programs      medicine residency, the initial target   or have Medicaid as their payer.
that utilize residents and students    population was high-utilizing            Ideally the program would
must plan to help patients make        patients from the residency              demonstrate savings to the
the transition to a new provider.      practice in Springfield. A grant from    Crozer-Keystone system at least
                                       the Aetna Foundation to support          equal to the cost of the social
This is not an easy process for
                                       two Super-Utilizer Fellows               worker’s salary and benefits.
many patients who already feel
                                       facilitated this work with the
abandoned by the health care                                                    In contrast, the program at
                                       primary purpose of educating
system.                                                                         LG Health decided to start with
                                       future physician leaders about the
                                                                                the Medicaid population but
                                       development and management
THE COLLABORATIVE -                                                             rapidly expanded to other target
                                       of SU programs.
PROCESSES                                                                       populations. The program at
                                       In January of 2014, a major health       WellSpan targets charity care
Target Population
                                       insurance company in the                 patients and those with Medicaid,
The structure and processes of a       Philadelphia market funded a full-       plus employees in the health
SU program can be tailored to fit      time nurse case manager position         system’s health plan.
the specific sub-set of the SU         to work with the Crozer SU               PinnacleHealth targets high
population that a given team or        program, targeting patients in the       users of inpatient and ED services,
organization chooses as the target     Crozer-Keystone system who have          regardless of payer, but focuses
group for their intervention. The      a Medicare Advantage policy with         primarily on Medicaid and self-pay
choice of target population is often   this payer and have significant          patients. The program in the
linked to the likely sources of        claims for their care. The funding       Lehigh Valley targets patients
funding as well as the needs of        supports a proof of concept that         with complex conditions with a
the community. For long-term           the SU team can significantly            behavioral health component.
sustainability, a SU program must      reduce claims for these patients,        They are currently negotiating
save money while improving             while maintaining or improving           agreements with area hospitals
quality of care. Programs must         quality of care.                         to receive data about patients with
eventually demonstrate a return on                                              frequent and preventable inpatient
                                       The Crozer-Keystone Health
investment (ROI) to their funders,                                              admissions and/or ED visits.
                                       System is considering an expansion
whether the funder is a payer like
                                       of the SU program at a later date,       Most of the programs have exclusion
Medicaid, a foundation or other
                                       but will need to find funding for a      criteria. All of them target adults, 18
grant-funding agency, or a
                                       full-time social worker. The target      and over. Most exclude patients who
program’s parent health system.
                                       population in this case would be         are pregnant, have an active cancer
SU work at the Crozer-Keystone         the patients that represent the          diagnosis, have high expenses due
Health System is a good example        greatest losses to the health            to a single catastrophic event, or
of how the choice of target            system, patients whose costs of          have only a serious mental health
population can depend on the           care are significantly higher than       diagnosis without chronic
program’s source of financial          the payments received. Typically,        medical problems.
support. Based in Crozer’s family      these patients either are uninsured




                                                                                                                          __
                                                                                                                          18
                                                                                                                          __
Patient Enrollment –
                                                                                       First Contact
                                                                                       The time and place of initial contact
                                                                                       with the potential SU patient are
                                                                                       critical determinants of program
                                                                                       success. The Camden program
                                                                                       receives real-time admission data
                                                                                       from the local hospitals which
                                                                                       enables a staff person from the
                                                                                       Coalition to make first contact in
                                                                                       the hospital and arrange for a home
                                                                                       visit after discharge. The staff in
                                                                                       Camden report there is an
                                                                                       advantage to meeting patients in
                                                                                       the hospital when they may be
                                                                                       most receptive to making positive
     Patient Identification                   hospital-owned health plans.             changes to manage their health.
     and Selection                            The program’s selection criteria         Programs that lack access to real-
                                              (definition of a super-utilizer,         time hospital data typically make
     All of the programs, except
                                              target population, and exclusions)       the first contact in a clinic or by
     Lehigh Valley, identify SU patients
                                              are applied to the patients in the       phone. WellSpan and LG Health
     through various hospital inpatient
                                              databases to identify potential          prefer to meet patients in their
     databases (admissions, observation
                                              candidates for the SU program.           PCP’s office, with a “warm hand-off”
     stays, and ED visits) and outpatient
                                              Programs also accept patients by         from the PCP. Crozer patients are
     records of health system-owned
                                              referral, typically from the patient’s   often introduced to the team while
     practices. Some have access to
                                              primary care team or inpatient           they are visiting their PCP in the
     high-risk lists from payers, including
                                              service. The patient selection           residency practice.
     Blue Cross or Medicaid, and
                                              process is essential to program
                                              success. Programs must prioritize        All of the programs consider home
                                              patients to assure the most efficient    visits to be an essential component
                                              use of limited resources.                of SU work. Home visits provide
                                                                                       insights to the patient’s living
                                                                                       environment, family and other
                                                                                       social relationships, nutrition, and
                                                                                       medication management, insights
                                                                                       that do not occur in the hospital or
                                                                                       office. There is good evidence
                                                                                       demonstrating that telephonic case




__
19
__
The program’s selection criteria (definition of a super-utilizer,
target population, and exclusions) are applied to the patients in
the databases to identify potential candidates for the SU program.



management is less effective than        All of the programs train their        and housing situations, and
in-person case management with           team members in motivational           substance abuse habits. One
the SU population.9 The SU               interviewing techniques. This          program uses PAM 13 for assessing
programs consider in-person              helps team members establish           patient engagement at enrollment,
contact – at home, in the                relationships that respect the         and every 3 months thereafter.
community, or the physician’s            patient’s autonomy and ultimately      Programs use a number of
practice – is critical to establishing   lead to patient engagement for         behavioral health instruments
strong relationships with patients       the duration of their enrollment in    including Montreal Cognitive
that can lead to improvement in          the SU program. The first contact      Assessment Tool (MoCa), Patient
their health and well-being.10           is also the time to begin an           Health Questionnaire (PHQ-9) and
                                         assessment of the patient’s            Self-Sufficiency Matrix, to name a
Patient Enrollment –
                                         “readiness for change” which is        few. After assessing patients’ needs
Engagement
                                         key to patient engagement.             and goals, a shared care plan or care
The initial contact is the time to       To-date team members have used         agreement is developed and
begin exploring the patient’s            clinical judgment and subjective       signed by the patient and program.
assessment of their health and           measures of readiness for change.      Patients are also asked to sign a
utilization patterns. The programs       Some programs have tried formal        HIPAA release form so that
offer to help patients with complex      instruments, such as the PAM 13        information from other providers
health problems and frequent             (See Exhibit 11), but have not         can be integrated into the patient’s
hospital use to achieve goals for        found them useful. Although            record and two-way care
better health and wellness. Team         helpful for a general population,      coordination can occur. Exhibit 11
members must gauge the patient’s         these instruments have been            contains a list of the assessment
willingness to change their use of       untested with high risk populations.   instruments used by the
hospital services and their self-        There is a need to develop             Collaborative’s programs.
assessment of health. Patients may       readiness for change instruments
be asked to identify barriers to care    that are appropriate for an SU
or discuss why they make frequent        population.
use of the hospital. The team offers
                                         Patient Assessments
to work with the patient to
navigate the system and coordinate       Programs use a variety of
services to achieve their goals          instruments to gather vital
for well-being.                          information to develop a detailed
(See Exhibit 9, the story about Victor   medical, psychological, and social
at Crozer. The language barrier was      history for each patient. Unlike
overcome when a Spanish-speaking
                                         histories taken in the typical
physician joined the team, Victor
then learned to schedule and keep        medical setting, the SU histories
appointments, secure better housing,     include the patient’s social
and manage his COPD outside of
the hospital.)                           supports, food needs, employment




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THE COLLABORATIVE                    However, problems with data access      for each patient, the data are
                                          and collection limited the data for     presented as rates, e.g. ED visits
     – OUTCOMES                           this report to Crozer, LG Health,       per patient per month and
     The SU programs in the               and WellSpan. Exhibit 12 shows          and inpatient admissions
     Collaborative typically started      the change in hospital utilization      per patient per month.
     small and gradually expanded.        (inpatient days and ED visits) before   For these three programs
     Three of the programs – Crozer,      and after enrollment in these three     collectively, inpatient admissions
     LG Health, and WellSpan –            programs. The pre-enrollment data       per month dropped 34 percent
     started with small pilot projects.   represent hospital utilization for      after enrollment in an SU program.
     As of December 31, 2013 these        each patient in the 18 months prior     On average, patients had 0.29
     three programs had served 138        to enrolling in an SU program. The      inpatient admissions per month
     patients, though they have grown     post-enrollment data represent the      prior to enrollment and 0.19
     significantly since then. The        utilization for each patient after      admissions per month after
     program at Pinnacle has served       enrollment. Because the post-           enrollment. The programs
     162 patients and the program at      enrollment periods vary in length       accomplished this reduction in
     Lehigh Valley has served 56                                                  hospital use in a number of ways.
     through December 31, 2013.

     To prepare for this report, the
     programs planned to consolidate
     the data from all five programs.




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On average, patients had 0.29 inpatient admissions
per month prior to enrollment and 0.19 admissions
per month after enrollment.



First and foremost, the programs        Exhibit 13 illustrates this point.    COMMON
encounter patients where they           The number of days spent in
are – in the hospital, the clinic,      the hospital decreased from
                                                                              CHALLENGES
the office or the community.            1.83 per patient per month to         Although the programs in the
Some patients had crucial social        1.53 per patient per month.           Collaborative use a variety of
service needs met, such as housing                                            models for providing services to
                                        If the average Medicaid expenditure
and transportation, that made it                                              SU patients, the programs face
                                        per hospital admission is
easier to manage their health as an                                           similar challenges, specifically
                                        approximately $75001, then a 34
outpatient.                                                                   with data, patient engagement,
                                        percent reduction in admissions
                                                                              care coordination and funding.
Some patients were connected to         for these patients would equal
a primary care provider. Most           $1,242,000 in estimated savings to    Challenges with Data
learned how to overcome barriers,       Medicaid for 138 patients over 12
                                                                              A robust healthcare data stream
advocate for themselves, and            months. If the average expenditure
                                                                              is critical to SU programs. Timely,
manage their health problems            per ED visit, not resulting in a
                                                                              comprehensive and accurate
outside the hospital.                   hospital admission, for adults
                                                                              utilization, claims and cost-related
                                        18-64 years of age is approximately
In contrast, ED utilization increased                                         data allow programs to 1) identify
                                        $10972, then a 12 percent increase
by 12 percent after enrollment.                                               potential SU patients and map their
                                        in ED visits would equal $54,498.96
This paradox can be explained                                                 location geographically, 2) design
                                        additional estimated expenditures
by how some SU patients are first                                             programs that meet the needs of the
                                        over 12 months. The net effect
engaged. Often the SU program                                                 identified population, including team
                                        would be an estimated savings
is notified that a patient has                                                composition, care processes, and
                                        of $1,187,501.04 for 138 patients
presented in the ED. An SU team                                               community partnerships, 3) develop
                                        over 12 months.
member engages the patient to                                                 program evaluation measures, and
                                        (See Exhibit 14 for pre and post      4) plan for the impact of SU work
determine if the patient’s needs
                                        enrollment estimated expenditures.)
can be met without an inpatient                                               on the health system sponsors such
admission. If the inpatient             Of the 138 patients presented in      as workforce re-deployment.
admission is averted, then the          these exhibits, 33 percent are no     Claims-related information allows
hospital records the encounter          longer enrolled in a SU program.      for a data-driven enrollment process.
as an ED visit. If the patient is       The vast majority (68 percent)        Claims data allow SU programs
admitted from the ED, the               successfully “graduated” from         to segment patients and tailor
encounter is recorded as an             the program and returned to a         interventions. Typically, patients
inpatient admission. To the extent      PCP for on-going care. Some           with cancer and trauma related
that SU programs can re-direct the      patients died (14 percent); a         admissions are excluded from
patient to resources outside of the     small percent dropped out of          participating in a SU program
hospital, the number of ED visits       the program or were lost to           because utilization is much less
may increase but the number of          follow-up. A very small number        amendable to intervention
admissions/days in the hospital         (4 percent) were asked to leave       in these groups.
will decrease. In essence, patients     the program for failure to
get back ‘life days’ that they          actively engage.
would have spent in the hospital.       (See Exhibit 15.)




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