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.
Amount Awarded $200,000.00
Awarded on: 6/11/2012
Time frame: 7/1/2012 - 6/30/2014
Grant Number: 70187