When nurse Janis Hovorka first visited at her home in rural Maine, Irene barely let her past the front door.
“She told me right off, ‘I don’t need any help,’” says Hovorka, a patient care manager for the Kennebec Valley Community Care Team in Maine. “She even gave me an example: She shoveled her deck in the wintertime, though she walked with a cane.”
Irene, who had multiple health problems and substantial hearing loss, was a prime candidate for KVCCT’s services targeting “super- utilizers”—patients who make frequent trips to the emergency room and have many hospital admissions. They are the one percent of the population that, according to a 2012 report from the Agency for Healthcare Research and Quality, accounts for 20 percent of the nation’s health care costs, and the five percent that accounts for 50 percent.
Irene had also been missing medical appointments. Her doctors wondered if she was really taking her medication.
The meeting went downhill from there. But then Hovorka noticed a plaque on the wall that mentioned Irene’s tenure as president of the local historical society. Hovorka asked about it; Irene opened up. Pretty soon she was talking about other things: her younger years with an abusive husband, the fact that she had very little family and couldn’t hear well enough to use a telephone, her desire to lose weight.
Hovorka was able to help Irene get on a walking routine, sign up for Meals on Wheels, and get hearing aids through a grant program.
“She really lived a different life because she wasn’t struggling to hear everybody, including the doctor,” she says.
Hovorka told Irene’s story at the Robert Wood Johnson Foundation’s Super-Utilizer Summit in Chicago last summer. The Summit brought together leaders of six Aligning Forces for Quality sites around the country working on pilot projects to reduce emergency room visits and hospitalizations for “super-utilizers,” a small group of patients that disproportionately strain the health care system.
Often destitute and alone, these patients need help figuring out where to go and how to get health care so they’re well-cared for and no longer require frequent visits to the ER.
Super-utilizer patients fall into several different categories—from patients with chronic conditions to those who struggle with behavioral health needs that impede their ability to engage in self-care, to frail elderly patients.
In some instances, addressing health care needs isn’t enough on its own—some patients may lack access to phones for providers to check in on them, while others may have trouble keeping their lights on. Some are isolated because they live in remote areas or lack a network of family and friends nearby.
At last summer’s meeting, representatives from the six sites—Maine; Cleveland; Humboldt County, Calif.; West Michigan; Greater Boston; and Cincinnati—shared strategies, struggles, and success stories for meeting the complex needs of the patients they work with.
Jeffrey Brenner, MD, executive director of the Camden Coalition of Healthcare Providers, provided big-picture perspective, addressing lessons learned across the sites and better ways to track data and broaden the scope of these pilot projects.
When Brenner began gathering data from hospitals and mapping health care use across Camden, N.J., in the early 2000s, 13 percent of patients accounted for 80 percent of hospital costs in the impoverished city. He and other primary care providers in the coalition began building relationships across the health care system—from hospitals to social workers and government agencies—to find better ways to care for these super-utilizers.
The six pilot Aligning Forces projects, funded by RWJF, grew out of Brenner’s work.
“These pilot projects really build on the work the Alliances are doing in their communities to improve the equality and the value of health care and to decrease disparities in their communities,” says Susan Mende, BSN, MPH, senior program officer for RWJF. “If you want to address quality, value, and disparities, you have to look at better ways of providing care for this group of patients.”
The differences are profound. In Cleveland, low-risk patients cost the health care system about $2,000 a year each. High-risk patients cost on average $54,000 a year each, says Alice Petrulis, MD, clinical champion of the Red Carpet Care program at MetroHealth.