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.
Amount Awarded $199,998.00
Awarded on: 6/19/2012
Time frame: 7/1/2012 - 12/31/2014
Grant Number: 70191