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.The Cleveland project will develop super-utilizer "clinics within clinics" in two National Committee for Quality Assurance level-three certified patient-centered medical homes within the MetroHealth System in Cuyahoga County, Ohio. The clinics will be staffed by interdisciplinary care teams and will partner with area hospitals to identify and monitor super-utilizers in the community. The clinics will also partner with a prominent faith-based organization to connect patients to nonmedical support. The project will target 75 patients insured by Medical Mutual of Ohio and 75 patients insured by Buckeye Community Health Plan who are in the top percentiles of emergency-department or hospital utilization and who have been diagnosed with diabetes, hypertension, heart failure, or a combination of those conditions. Deliverables will include: (1) development of the two super-utilizer clinics; (2) serving up to 150 patients by the end of the grant period; and (3) an evaluation of the project's impact on patient-quality outcomes, total health care charges, and utilization of emergency departments and in-patient services.
Amount Awarded $200,000.00
Awarded on: 6/27/2012
Time frame: 7/1/2012 - 9/30/2014
Grant Number: 70237