Reducing inappropriate use of emergency departments, decreasing readmissions, and improving outcomes for super utilizers in Maine

This project is one of six that aim to reduce inappropriate use of emergency departments, decrease avoidable hospital readmissions, and improve outcomes for health care super-utilizers (high-cost, high-needs patients) in Aligning Forces for Quality (AF4Q) communities. The Camden Coalition of Healthcare Providers will provide each of the six participating AF4Q communities with technical assistance to develop a locally tailored super-utilizer model to provide these high-needs individuals with patient-centered, coordinated medical and social services. This project will build on a statewide community care team (CCT) model designed to provide care to super-utilizer patients of patient-centered medical homes. The eight CCTs in Maine provide high-needs patients with multidisciplinary care-management services that address the patients' medical and social needs. The CCT Steering Committee, which manages the eight teams, will establish a selection process with explicit criteria to identify one of the eight CCTs as the "vanguard" community-based, super-utilizer team. This vanguard CCT will work directly with the Camden Coalition to build the team's capacity to identify and manage super-utilizers and will share its experiences and lessons learned with the other seven CCTs in Maine. Deliverables will include selection of one vanguard CCT as the super-utilizer team; acquisition and use of data to assist CCTs to identify super-utilizers and track their outcomes; use of health information technology to support individual patient management, and development of methods to strengthen CCT connections to nonclinical community resources, including the faith-based community, YMCAs, and volunteer organizations.

Grant Details

Amount Awarded $199,998.00

Awarded on: 6/19/2012

Time frame: 7/1/2012 - 6/30/2014

Grant Number: 70191