Robert Wood Johnson Foundation Awards $2.1 Million in Grants to Improve Care, Reduce Costs for Most Expensive Patients

    • October 11, 2012

Princeton, N.J.—The Robert Wood Johnson Foundation (RWJF) today announced $2.1 million in grants through a new initiative aimed at solving one of the most intractable problems in health care: the overuse of our nation’s emergency departments and hospital inpatient services by so-called “super-utilizer” patients. Health care spending in the United States is unevenly distributed, with the sickest 5 percent of patients causing more than 60 percent of health care costs.

The “super-utilizers,” highlighted in a feature by Atul Gawande, MD in The New Yorker last year, make frequent return trips to emergency departments (EDs) or repeated inpatient hospital stays. Hospital services are often the most expensive and least efficient way to treat these patients, and super-utilizer hospital overuse poses a significant challenge to overall health care delivery system reform.  

The Foundation has awarded $200,000 to each of six organizations that operate quality improvement alliances in RWJF’s Aligning Forces for Quality (AF4Q) initiative, which serves as the Foundation’s signature effort to lift the overall quality of health care and provide models for national reform in 16 targeted communities across the United States.

Grant recipients include AF4Q alliances that serve Boston; Cincinnati; Cleveland; Humboldt County, Calif.; Maine; and Western Michigan. These regions have all made great strides to improve the quality of care delivered to patients overall in their areas. Now, they are tackling the additional challenge of improving care and reducing unnecessary costs and spending for super-utilizers in the system.

The grants are based on the successful work of Jeffrey Brenner, MD, founder and executive director of the Camden Coalition of Healthcare Providers (CCHP), which set out to improve the quality and cost of health care delivery for super-utilizers in Camden, N.J. RWJF previously awarded Brenner and the coalition $900,000 to provide technical assistance to each project.

“Like every community nationwide, these six communities have health care hot spots where the  most complex patients overuse emergency rooms and drive up the overall cost of care in large measure because they do not get the coordinated care, both medical and social, that they need,” says Susan Mende, BSN, MPH, RWJF senior program officer. “The AF4Q alliances are the right groups to develop and implement effective models to meet the needs of super-utilizers outside the emergency room. Each community’s patients and needs are different, so this program will help us learn what works best in a variety of settings, so we can provide models for others to replicate.”

Today’s grant is a natural extension of RWJF’s investment in CCHP, which began in 2005. The six alliances will work to review hospital records to identify super-utilizers in their areas. Typically, these are patients with multiple chronic medical problems and social complexities.

The goals of the pilot programs are to keep patients healthy, and improve the quality of care they are receiving, including coordinating social and medical interventions. The program will also reduce unnecessary costs by identifying alternatives to hospital admissions that will reduce hospital readmission rates and unnecessary ED visits.

Specifically, the six alliances will work directly with CCHP and Brenner to create a network of needed medical and social services through care teams that serve the patients directly, referring patients to super-utilizer clinics and working with primary care practices. The alliances will provide coaching and support for local physicians to enable targeted care and case management for the super-utilizer patients.

“This grant creates a great opportunity to not only help the neediest, most expensive patients in these communities, but to learn how to take this work to scale,” says Brenner. “This is a national challenge, but it can only be solved one community at a time.”

Grant Recipients

Massachusetts Health Quality Partners (Greater Boston)

Greater Boston Super-Utilizer Pilot Project

This project will leverage a pilot community-based team program (Healthy Lives) that has shown initial success at improving quality outcomes and reducing costs for super-utilizers through a combination of active engagement, care coordination, and wellness activities. The model will be expanded by adding a part-time case manager to focus on helping connect patients to neighborhood-based social services and consumer and faith-based organizations.

The Health Collaborative (Cincinnati)

ED Care Coordination Pathway Program Pilot

This project will leverage an existing ED care coordination program to develop a pilot community-based outreach team. The team will include a community health worker (lead) and AmeriCorps volunteers to coordinate services and support patients through a network of medical, social service, and behavioral health services. A multi-disciplinary clinical advisory team of social workers, hospital case managers, physicians, and behavioral health staff will oversee the patients’ care.

Better Health Greater Cleveland

Red Carpet Care for Patients in Greatest Need: The Greater Cleveland Super-Utilizer Project

This project will develop super-utilizer “clinics-within-clinics” in two National Committee for Quality Assurance level-3 certified patient-centered medical homes in Cleveland. The clinics will be staffed by interdisciplinary care teams and will partner with 10 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 non-medical support.

Aligning Forces Humboldt

Care Coordination for Emergency Department Super-Utilizers

This project will develop a community-based team through a collaborative effort between two existing, successful programs (the Care Transitions Program and Priority Care) that provide case management and nurse-led care coordination. The most distinctive aspect of this proposal is the rural setting in which the project will operate, which will provide important insight for developing super-utilizer models in similar settings.

Maine Quality Counts

Maine Patient-Centered Medical Home Pilot – Developing a Vanguard   

This project will enable Maine’s statewide Community Care Team (CCT) super-utilizer program to select and develop one of its current CCTs to be a “Vanguard” team to serve as a model for informing the future of the program. The existing CCT program consists of eight community-based, multi-disciplinary super-utilizer teams that work with PCMH pilot practices to identify high-need patients who would benefit from additional multi-disciplinary care management support.

Alliance for Health (Western Michigan)

Systematic Identification and Care of High-Frequency Emergency Department Utilizers

This project will leverage an existing super-utilizer care clinic in Kent County, growing the clinic’s reach into a multi-hospital model. They will develop a HIPAA-compliant interaction between all Kent County EDs and clinics via the local health insurance exchange.


About the Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to health and health care, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, measurable, and timely change. For 40 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. For more information, visit Follow the Foundation on Twitter or Facebook

About Aligning Forces for Quality

Aligning Forces for Quality (AF4Q) is the Robert Wood Johnson Foundation’s signature effort to lift the overall quality of health care in targeted communities, as well as reduce racial and ethnic disparities and provide real models for national reform. The Foundation’s commitment to improve health care in 16 AF4Q communities is the largest effort of its kind ever undertaken by a U.S. philanthropy. AF4Q asks the people who get care, give care and pay for care to work together to improve the quality and value of care delivered locally. The Center for Health Care Quality in the Department of Health Policy at George Washington University School of Public Health and Health Services serves as the national program office. Learn more about AF4Q at Learn more about RWJF’s efforts to improve quality and equality of care at  

Media Contacts

Melissa Blair

Robert Wood Johnson Foundation (609) 627-5937

Additional Media Contact: Aaron Cohen

(202) 261-2869