Reducing inappropriate use of emergency departments, decreasing readmissions, and improving outcomes for super utilizers in Humboldt County, Calif.

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 develop a community-based team--composed of the clinical champion, leaders from other care-coordination programs, an RN case manager, the patients' primary care provider, emergency department staff, and hospitalists--to focus on super-utilizer dual eligibles (beneficiaries whose non-Medicare coverage is covered by Medicaid) who are patients of both the local hospital (St. Joseph Hospital) and the Eureka Community Health Center (ECHC). Although these patients receive primary care at ECHC, they continue to visit the hospital emergency department frequently. The project, therefore, aims to improve their health outcomes while decreasing their use of the emergency department. Deliverables will include providing care coordination and medical, social, behavioral and substance abuse services to 30 patients; building communications channels among small practices, local hospitals and ECHC; and developing coordinated systems of care for super-utilizer patients at ECHC.

Grant Details

Amount Awarded $199,996.00

Awarded on: 6/21/2012

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

Grant Number: 70190