Care Management for Super-Utilizers Program

Project Term: 24 months; Ended 2018
Grant Amount: $148,183

This project established an innovative pilot to serve “super-utilizers” – frequent utilizers of Partnership Health Center’s services and local emergency rooms. Super-utilizers are the approximately one percent of patients accounting for twenty-two percent of total health care expenditures, and they often suffer from multiple health conditions and socioeconomic barriers to care which contribute to multiple emergency room visits and hospital admissions. The project created a team consisting of a licensed clinical social worker, registered nurse, and primary care provider to coordinate care and conduct home visits and follow-up calls with select patients to address their medical, behavioral and social needs. The health center also successfully redesigned their care approach to prioritize patient needs and focus on interventions that lessened the cycle of hasty emergency department use and inpatient stay. Outcomes included reductions in the number of emergency department visits and inpatient stays and increased self-efficacy among patients. Recognizing the success of the program, Medicaid changed its reimbursement models for this super-utilizer approach to care.


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