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

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 Cincinnati project will leverage an existing emergency department care coordination program to develop a pilot, community-based, super-utilizer outreach and clinical care team that will serve high-needs patients receiving care from University Hospital. The outreach team will include a lead community health worker and AmeriCorps volunteers who will coordinate patient outreach, connect patients to community resources, and support patients through a network of medical, social, and behavioral health services. A multi-disciplinary clinical advisory team of physicians, social workers, hospital case managers, and behavioral health staff will oversee patient care.Deliverables will include: (1) the development and implementation of the super-utilizer team; (2) the provision of care for up to 30 patients by the end of the grant period; and (3) the development of a support group for super-utilizers.


Grant Details

Amount Awarded $200,000.00

Awarded on: 7/9/2012

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

Grant Number: 70188


Health Improvement Collaborative of Greater Cincinnati

2100 Sherman Avenue, Suite 100
Cincinnati, 45212-2736


Nancy M. Strassel
Project Director


Judith Warren
Project Director