Improving care by targeting ‘superutilizers'


Where: CareOne Clinic at the University of Florida in Gainesville.

The issue: Targeting preventable hospital readmissions and poor coordination of care for “superutilizers,” patients with frequent ED visits and hospitalizations.

Background

The university's vice-chair of clinical affairs, Robert Leverence, MD, FACP, and its chair of medicine, Robert Hromas, MD, FACP, obtained Medicaid grant funding to begin a superutilizer program and post-discharge clinic in November 2012.

How it works

The clinic targeted recent high utilizers of the hospital as its first patients. “We initially queried our EMR for patients with more than 8 ED visits in the prior 12 months, and that generated a list of about 470 patients,” said Deepa Borde, MD, assistant professor at the University of Florida Division of Hospital Medicine and medical director of the CareOne Clinic. One hundred forty-seven patients participated in the initial clinic pilot.

The clinic is open from 8 a.m. to 12 p.m. Monday to Friday and is staffed by a primary care physician, a social worker, and a nurse. A pharmacist and a pain and addiction psychiatrist are also available 2 half-days per week. The initial appointment often takes several hours to allow each clinician to perform a full needs assessment, Dr. Borde said.

The number of visits varies for each individual patient, Dr. Borde noted, from as few as 1 to 2 to as many as 7 or 8, depending on complexity. “We're a transitional clinic, so we carry these patients for a short period of time. When the primary triggers for their recurrent ED visits are fully addressed, we then arrange a referral to a primary care provider,” she said.

Patients who have graduated from the clinic and then are later readmitted to the hospital may or may not be seen at the clinic again, Dr. Borde said. “If it is truly an avoidable admission, we will see them again,” she said. However, she said, many of these patients will be readmitted despite best efforts simply because they are medically frail.

“There are times when they come in and it's appropriate,” she noted. “So if we find we have already referred them to a new primary care doctor and they were appropriately admitted, we don't need to intervene.”

Results

According to an analysis of 147 superutilizers, when comparing 6 months before versus 6 months after the first clinic visit, there was a 30% reduction in ED visits and a 25% reduction in hospitalizations. This effect was magnified in the uninsured population, which experienced a 46% reduction in ED visits and a 48% reduction in hospitalizations. The findings were presented as an abstract at the Society of Teachers of Family Medicine's annual spring conference in May.

Updated data since then have shown similar trends, Dr. Borde noted. “We've been quite pleased, especially considering that we're only open half-days and also given that most of our patients are post-discharge patients, which limits the time and resources spent on superutilizer patients,” she said. Most established superutilizer programs are open all day and may provide after-hours call coverage, she noted.

The post-discharge patients comprise 75% of the clinic's patient population, Dr. Borde said. These are patients who are discharged from the hospital or ED who are unable to obtain a timely appointment with a primary care physician or who have no primary care physician and need close follow-up and coordination of care. Only superutilizers were included in the analysis of ED and hospital utilization, but all patients were included in the financial analysis, Dr. Borde said.

Preliminary analysis shows that the clinic can sustain itself financially, she noted. There was a reduction in unreimbursed hospitalizations, corresponding to an estimated $1.2 million in savings (based on the average collection per admission), which covered the cost of the clinic during the same time period.

“The improved coordination of care of uninsured patients in the outpatient setting with special attention to treating mental illness and addiction has been the key to our success,” Dr. Borde said. She credits most of the clinic's improved outcomes to the work of its pain and addiction specialist, Robert Rout, MD, and social worker, Jacqueline Pinkney.

The challenges

Dr. Borde said the biggest challenge has been finding a place for patients to go after a successful stint with the clinic, since local health departments and primary care clinics are sometimes unprepared or unable to manage those who require complex specialty care. Cost of medications can also pose problems, she said, so the clinic pharmacist does a cost analysis to determine the most affordable regimens for each patient.

She also mentioned another, more basic challenge: getting patients in the door. At first, she said, when a separate access center was calling patients to recruit them to the clinic, they were reluctant to participate. Now, Dr. Borde said, “All the inpatient case managers get an email every day if they are taking care of a patient who is a frequent visitor.” They are encouraged to consider referring the patient to the clinic.

The clinic also recently hired a premedical student to serve as a health coach and help with coordinating care. “She will go and see patients in the hospital to introduce patients to the program so they'll have a better idea of what this program is about,” Dr. Borde said.

Lessons learned

Sometimes the reasons behind someone's complicated condition have an unexpected explanation, Dr. Borde said. She gave the example of a patient who had been stealing his wife's pain medications and was discharged from his primary care practice because he had missed several appointments.

When Dr. Borde asked the patient why, he told her he had become severely depressed after his son was killed in a motor vehicle accident. He self-medicated with drugs and alcohol and “everything kind of unraveled,” Dr. Borde said. “This man was a successful business owner and he was married, and after he lost his son he lost everything.”

Dr. Borde and her staff put the patient back on antidepressants, restarted a previous thyroid medication, referred him to an endocrinologist, and lobbied his previous primary care practice to reinstate him. As a result, she said, he has had no additional ED trips after his initial clinic visit.

How patients benefit

The benefit to patients goes beyond costs, Dr. Borde said. “If you look at the literature, prior studies have shown that high ED utilization is associated not only with higher morbidity but also mortality, so we know that if we can better manage patients in the outpatient setting, we are not only improving their quality of care but potentially reducing their mortality,” she said.

Next steps

The clinic recently hired a clinical psychologist who specializes in pain and is holding group sessions to teach chronic pain patients about nonpharmacologic pain management, as well as providing individual therapy and cognitive behavioral therapy. “We're excited about the possibility of evaluating the impact of a mental health intervention on hospital and ED utilization,” Dr. Borde said.

Words of wisdom

A supportive administration interested not only in cost containment but also in quality of care is key to success, Dr. Borde said. As well, those interested in developing a similar effort should try to put together a team of clinicians that has “a good combination of optimism and realism,” she noted. “You need key players from social work… you need a strong physician advocate, a nurse case manager or a nurse manager, and ideally a community health worker.”