Nurse and patient conversation

Great Plains QIN recently drew a large audience for the webinar, “Improving Care Coordination by Working with Super-Utilizer Patients.” LaraShadwick, MBA, Mountain Pacific Quality Health, shared insights on a collaborative project in Montana to address super-utilizer patients.

The term “super-utilizer” describes individuals whose complex physical, behavioral, and social needs are not well met through the current healthcare system. As a result, these individuals often bounce from emergency department to emergency department, from inpatient admission to readmission or institutionalization—all costly, chaotic and ineffective ways to provide care and improve patient outcomes.¹

The Montana project focused on using “ReSource Teams” that consisted of a registered nurse and a community health worker with technology as an extender. The community health worker met the patient at the patient’s home and connected to other providers utilizing video conferencing.  The patient base included patients with two or more inpatient admissions and/or emergency department visits in six months who were not ‘end of life’. Building relationships with patients and meeting face-to-face with them was paramount. The community health workers were key in identifying what drives the patient to be compliant.  The project has reduced acute care utilization, improved patient outcomes and shown significant return on investment.

Shadwick encouraged attendees to identify who is “at the table” in their communities in the three realms of patient care—medical, behavioral and social determinants of health. The medical community is the traditional—hospitals, home health, nursing facilities, clinics, physician clinics, specialty clinics community health centers and Federally Qualified Health Centers (FQHCs), which is where the bulk of the funding and care is done in a volume-driven manner. Behavioral health includes counseling, case management, inpatient psych units, etc., and has received more attention in the last decade. Social determinants of health look at how patients with few means get affordable housing, transportation, financial assistance, etc. The players in this third realm are different in every community and may include organizations such as area agencies on aging, food banks, faith-based organizations. Salvation Army, food kitchen, etc. Shadwick states, “One key that I would suggest each community try and go after is a format that works for coordinated care in all of these realms.”

Shadwick described barriers to care coordination in a rural state, such as large geographic areas between healthcare hubs, provider shortages, timely access to primary care, transportation challenges, affordable housing, etc.  Many of the models found in the literature did not address complex care patients in the rural setting so something new had to be developed for the Montana project. Shadwick stated, “Complex care patients are roughly 1% of the patients in any given population, but they account for 22% of healthcare costs. Complex care patients impact all stakeholders in the community because they take an inordinate amount of time, dollars and are often the source of frustration for providers.”

Learn more about specific interventions, project successes and total cost savings from the Montana super-utilizer project by clicking here to listen to download the slides and listen to the webinar. An additional opportunity to learn more and submit questions to Lara Shadwick will be available at a coaching call on July 25, 2018, at 12:15 p.m. Click here to learn more and register.

  1. 2013 Super-Utilizer Summit: Common Themes from Innovative Complex Care Management Programs