Project Term: 24 months; Aug 2016 – Jul 2018
Grant Amount: $148,183
This project will employ a targeted approach to treating so-called “super-utilizers,” the approximately one percent of patients accounting for 22 percent of total healthcare expenditures. Super-utilizers often suffer from multiple chronic conditions, mental health concerns, and myriad socioeconomic barriers to care, contributing to multiple ER visits and hospital admissions. Partnership Health Center’s Super-Utilizer Care Management teams will, through home visits and a partnership of community resources, deliver comprehensive care to these patients with the goals of reducing emergency department use, hospital admissions and healthcare costs; increasing patient health and satisfaction; and transitioning patients to primary-care settings.