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

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 Greater Boston project will target super-utilizers living in diverse communities near the Beth Israel Deaconess Medical Center. It will expand staffing (a case manager) for Healthy Lives, a pilot program for a community-based team that has shown initial success in improving quality outcomes and reducing costs for super-utilizers. The team works to create a stable system of medical and social support for patients and their families by linking them to medical and behavioral health providers and a network of social service providers and faith-based organizations. Deliverables will include: (1) expanding the staffing and scope of the community-based super-utilizer team; (2) serving 30 patients by the end of the grant period; and (3) building a coalition of consumer and faith-based organizations to raise public awareness of super-utilizers and develop community organizing and educational programs to create sustainable approaches to their care.

Grant Details

Amount Awarded $200,000.00

Awarded on: 6/11/2012

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

Grant Number: 70187