WORKING WITH THE SUPER-UTILIZER POPULATION
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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:
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.
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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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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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.
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__
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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__
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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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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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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__
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
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__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.
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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
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__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
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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
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__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,
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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
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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
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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.
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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
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__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
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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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20
__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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21
__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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