Cleveland Medical Center Aims to Improve Care for Super Utilizers

A man sits on a bed at a shelter and hooks himself to a CPAP machine.

A man in a Cleveland homeless shelter hooks himself up to a respiratory machine.

If a health system delivers more services to patients with chronic conditions, will it lose money or save money?

To answer this question, the MetroHealth Medical Center, in Cleveland, is conducting a study of what it calls the Red Carpet Program. As the name suggests, MetroHealth is figuratively rolling out a red carpet for 150 patients with diabetes, hypertension, and heart failure and provide more care to these patients for 18 months. Then it will compare the before and after costs.

The project is funded through a grant from the Robert Wood Johnson Foundation through its Aligning Forces for Quality (AF4Q) initiative. Better Health Greater Cleveland, which is based at MetroHealth, is an AF4Q site. The program is modeled on the work of the Camden Coalition of Healthcare Providers and Jeff Brenner, MD. During monthly conference calls, Brenner and his staff give MetroHealth technical advice. RWJF has provided funding for Brenner and his staff to help six AF4Q sites to institute programs aimed at high utilizers.

“It’s too early to know if the program is working," Petrulis explains, "but we expect to show that one result of delivering better care is that costs will be lower.”


In January, MetroHealth, the public hospital in Cuyahoga County, assigned nurse practitioners (NPs) to help each of 150 patients get better care from the health system. Among these patients, 75 are members of Buckeye Community Health Plan, a Medicaid managed care plan, and 75 have health coverage from Medical Mutual of Ohio, a commercial insurer. The two insurers are paying the salaries for the nurse practitioners. When the program ends next summer, MetroHealth will analyze the patients’ health and how much was spent.

Brad Lucas, MD, the chief medical officer for Buckeye Community Health Plan, recognizes the value of having NPs work closely with these patients. “The NPs are part of the team of providers who will become experts in solving problems related to housing, substance abuse treatment, and transitions of care, which often exacerbate patients’ health conditions,” he says. “The team will seek to eliminate barriers to care so that the patients can get timely and appropriate preventive care outside the emergency room.”

The NPs use patient registries to track the care of each patient, and make home visits to learn what each patient needs. A goal of the program is to empower patients to care for themselves. “We asked the NPs and the patients to keep journals,” says Alice Stollenwerk Petrulis, MD, MetroHealth’s medical director for care management. “We also give the patients phones and calendars to track their appointments, and pedometers to track their daily activities.

“By working closely with these patients, we expect to see a drop in emergency room use and in hospitalizations as well,” Petrulis explains. “Then, next summer, we will evaluate each patient’s health status and how much money we saved in ER visits and hospitalizations.”

Before it can evaluate its success, MetroHealth must first collect a variety of data on each patient, including blood pressure, lipid, and HbA1c levels; and whether patients are filling and completing their prescriptions and meeting with their physicians, Petrulis says. The hospital also is measuring patient satisfaction.

“We’re making sure the patients have what they need so they can get to the doctor and get the best care,” Petrulis explains. “It’s too early to know if the program is working, but we expect to show that one result of delivering better care is that costs will be lower.”

Demonstrating that the program can reduce costs may attract the attention of other insurers besides Buckeye and Medical Mutual. “We would like to partner with more health plans to do this work because we have a large number of patients who would benefit,” she says.

Demonstrated success would help Buckeye Community Health Plan to expand the program, Lucas adds. “Receiving care primarily in the emergency room does not work well for those who are the sickest and most costly among us,” he says. “We hope that the Red Carpet Program will be a successful pilot so that others will buy into this idea.

“Also, we can see how the lessons learned from this program could be extended to other populations and other programs—particularly our pregnant members who live in the highest risk census tracts. If they have problems with housing or substance abuse they will not be focusing on prenatal care visits,” he adds.

“But step one is to see if the program works when it is analyzed in a critical fashion. If there is success, then we all need to figure out together how it can be staffed and maintained,” Lucas concludes. 

In Practice

Three Ways MetroHealth Defines a Super Utilizer

  • Number of visits to the ER
  • Number of hospitalizations in the past year
  • Diagnosis of diabetes, hypertension, or congestive heart failure.

Source: MetroHealth, Cleveland, Ohio.