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Implementing Brenner’s Collaborative Super-Utilizer Model
Barry J. Jacobs, Psy.D., William Warning, MD, Steven Sluck, DO, Stephanie Maruca Watkins,
DO
Crozer-Keystone Family Medicine Residency Program—Springfield, PA
Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.
Session #D4aOctober 6, 2012
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Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
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Objectives
Describe the Brenner Collaborative Super-Utilizer Model using research data to demonstrate its efficacy for improving clinical outcomes and reduce healthcare costs
Illustrate a successful implementation through presentations of two case studies
Identify key operational and training components for effective collaborative super-utilizer teams
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Learning Assessment
A learning assessment is required for CE credit.
Attention Presenters:
Please incorporate audience interaction through a brief Question & Answer period during or at the
conclusion of your presentation.
This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy
accreditation requirements.
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Today’s Talk
The crucial issue of utilization in today’s healthcare
What is a “super-utilizer”? What are the elements of an SU program
using collaborative team interventions? Case of SD, a hospital SU Case of CB, an ER SU SU Fellowship Keys to SU operations and funding
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High Utilization Driving Healthcare Costs Premise: Our most medically and
psychosocially complex patients use disproportionate amounts of healthcare resources
Drive up total healthcare costs
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1%5%
10%
50%
22%
50%
65%
97%
$26,767
$90,061
$40,682
U.S. Population Health Expenditures
$7,978
Distribution of Health Care Expenditures for the U.S. Population, According to Magnitude of Expenditure, 2009
The sickest 10% of patients account for 65% of the health care expenses. Dollar amounts are annual mean expenditures per patient. Data from the 2009 Medical Expenditure Panel Survey, adapted from the Commonwealth Fund.
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What is a “High-” or “Super-Utilizer”? Well researched, well defined problem with a
few successes. 4 Major Studies were reviewed
2010 Mount Sinai School of Medicine 2009 Midwestern Urban Hospital 2009 Camden Coalition of Healthcare Providers 2006 IOM Report
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Characteristics of High-Utilizers Most are insured, 60% public insurance Only 15% uninsured Over 80% have identifiable PCPs More utilization of health services in general Diagnoses vary greatly Ages 25-44 and over 65 Addiction and mental health issues make it more
difficult for patients to navigate system
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Usage Patterns
High utilizers use the ED >3x per year 5-8% of ED patients account for 21-28% of
visits Over 50% sought care at 2 or more EDs 70% of frequent visits were on evening or
night shift
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Who is Jeff Brenner, MD
Frustrated family MD Closed solo practice in
Camden, NJ Began looking at data
about city’s healthcare trends
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Brenner (cont.)
The Camden Study-An ED Alternative 5 year study of 380,000 visits at 3 EDs 1% of patients 40,000 visits, $46 million
cost Top 35 utilizers generated $1.2 million in
charges each month
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Brenner (cont.)
Formed Camden Coalition of Healthcare Providers in 2002
Developed Camden Healthcare Database Formed relationships with outpatient and
inpatient providers, as well as social service agencies, throughout city and state
Promulgated “hot-spotting” or “super-utilizer” model of collaborative intervention
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Components of SU Interventions Data mining (sometimes across health systems and
agencies) to create SU list Creation of collaborative multi-disciplinary teams:
physicians/nurses practitioners, case managers, social workers, mental health consultants, health educators
Assessment procedures and outcome measures Relationship-building with other healthcare and
social service providers to improve care transitions and marshal community resources
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The Camden Study
35 highest utilizers were put into Camden Coalition Project
Social Worker, CRNP, Case Managers, Health Educators, cost $300,000/yr
35 patients received individualized case management services via the Coalition
Monthly charges reduced from $1.2 million to $531,000
For every $1 spent $1.44 was saved in hospital costs
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Who are we?
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Crozer-Keystone Health System 5-hospital health system, with 6800 employees, in
western suburb of Philadelphia Delaware County: pop. of 550,000;
socioeconomically and culturally diverse; inner ring, decaying suburbs and more middle-class neighborhoods
Residency: 9-9-9 program, founded in 1994; two family health centers; one an FQHC
Two fellowship programs (SU and sports medicine) Clinical affiliation with Temple University School of
Medicine
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Timeline of Our SU Project
Pilot initiated in summer of 2011 Joined FMEC SU Learning Community Feb. 2012: SU presentation to health system’s
administrators by Jeff Brenner; SU team presented two cases
Led to health system initiating High Utilizer Program At that presentation, announcement of SU
Fellowship, co-sponsored by Crozer and Cooper Health System in New Jersey
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Our SU Team (with Dr. Brenner)
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SU Team Activities/Outcomes Graduated one of pilot cases; other has
made gains but still underway Developed data mining and SU selection
process Selected 5 more cases (at 3 outpatient
centers) for this academic year Working on assessment procedures, team
coordination processes and outcome measures
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Case Report: Meet SDCase Report: Meet SD
SD is a 64 yo male who SD is a 64 yo male who has lived in the Delaware has lived in the Delaware County community for County community for years.years.
He is a retired electrician He is a retired electrician and lives with his wife.and lives with his wife.
Wife works part time 3 Wife works part time 3 days a week.days a week.
In 2010 -2011 - 13 In 2010 -2011 - 13 Admissions for CHF.Admissions for CHF.
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Past Medical HistoryPast Medical History BPHBPH CADCAD CHF (7-2010 EF = 30-35 % ) CHF (7-2010 EF = 30-35 % )
CKDIIICKDIII CVACVA Depression/Anxiety/Depression/Anxiety/
InsomniaInsomnia Diabetes Mellitus IIDiabetes Mellitus II GoutGout HypercholesterolemiaHypercholesterolemia HTNHTN HypothyroidismHypothyroidism
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Past Surgical History Past Surgical History
CABG 1998CABG 1998 ICD placement x2 ICD placement x2
(11/2008 & dual (11/2008 & dual chamber 3/2010)chamber 3/2010)
L4-L5 LaminectomyL4-L5 Laminectomy MastoidectomyMastoidectomy
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Date Adm/ER visit Reason2/1/10 Adm PNA/CHF2/9/10 ER Anxiety2/15/10 ER Anxiety2/18/10 ER Insomnia3/8/10 ER Ear pain3/26/10 Adm- ICU CHF4/7/10 Adm CHF/PNA4/25/10 Adm CHF7/4/10 ER Back pain7/6/10 Adm CHF/PNA7/11/10 Adm CHF7/24/10 Adm CHF7/27/10 Adm CHF8/18/10 Adm CHF10/14/10 Adm CHF10/22/10 Adm CHF11/13/10 ER SOB11/22/10 Adm CHF1/22/11 ER Left w/o being seen2/23/11 Adm CHF
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1 year Charges = $520,000; Receipts: $90,000;
Inpatient Admissions: 12; ED visits: 7
Leng
th
of
Sta
y
• IP Admit • ED Visit
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Comprehensive Medication Comprehensive Medication ManagementManagement
Opportunity Within the Opportunity Within the Patient-Centered Medical Patient-Centered Medical Home (PCMH)Home (PCMH)
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Medication ManagementMedication Management6-20116-2011
Aggrenox one po dailyAggrenox one po daily Aspirin 81 mg po dailyAspirin 81 mg po daily Lopid 600 mg po bidLopid 600 mg po bid Lipitor 80 mg po hsLipitor 80 mg po hs Zetia 10 mg po dailyZetia 10 mg po daily Lantus sc dailyLantus sc daily Lasix 40 mg po bidLasix 40 mg po bid KCl 20 mEq po dailyKCl 20 mEq po daily Norvasc 10 mg po dailyNorvasc 10 mg po daily Enalapril 20 mg po dailyEnalapril 20 mg po daily Sotalol 80 mg take ½ po Sotalol 80 mg take ½ po
bidbid Coreg 25 mg po bidCoreg 25 mg po bid Toprol XL 100 mg po dailyToprol XL 100 mg po daily
Colchicine po prn gout Colchicine po prn gout attacks attacks
Vit D 50000 units po q Vit D 50000 units po q other monthother month
Flomax 0.4 mg po dailyFlomax 0.4 mg po daily Levothyroxine 50 mcg Levothyroxine 50 mcg
po dailypo daily Celexa 20 mg po dailyCelexa 20 mg po daily Ativan 0.5 mg po hsAtivan 0.5 mg po hs Melatonin 3 mg po hsMelatonin 3 mg po hs Diphenhydramine 25 Diphenhydramine 25
mg capsmg caps Omeprazole 40 mg po Omeprazole 40 mg po
dailydaily
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Identify, Resolve and Prevent Drug Identify, Resolve and Prevent Drug Therapy ProblemsTherapy Problems
Adherence
Effectiveness
Safety
Indication
4 Areas
Cipolle, R., Strand, L., Morley, P-Pharmaceutical Care Practice-The Clinicians Guide-2004-2nd edition-McGaw Hill
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AdherenceAdherenceProvider Provider NoteNote
CommentsComments
Jan & June 2010Jan & June 2010
CardiologistCardiologist
““Called Rx. Not on beta blocker. Rxist Called Rx. Not on beta blocker. Rxist doesn’t think pt understands doesn’t think pt understands medications. Instructed to take all meds medications. Instructed to take all meds in bag to PCP to review.”in bag to PCP to review.”
““did not bring med list, does not know did not bring med list, does not know what he is taking.”what he is taking.”
Inpatient Inpatient Progress notesProgress notes
Frequently noted as non-compliant.Frequently noted as non-compliant.
Retrospective Medical Record Chart Review Jan 2012
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Adm Date
ER Med History
Med Admin Record
Chart Discharge Note
Patient Discharge Instr.
2/1/2010 Toprol XL ??Toprol XL 25 mg 0900
Coreg 3.125 mg bid Coreg 3.125 mg bid
3/26/2010
Toprol XL 50 mg hs
Metoprolol 50 mg bid 50 mg twice daily
transfer to Bryn Mawr
4/7/2010Toprol XL 50 mg hs
Toprol XL 50 mg 0900
Toprol XL 50 mg hs
Toprol XL 50 mg daily
8/18/2010
No recorded medications
No beta blocker administered
"dc on home meds"
No Beta Blocker on Patient discharge instructions
10/14/2010
Coreg 25 mg q12hrs Coreg 25 mg bid not noted Coreg 25 mg bid
11/22/2010
Toprol XL 50 mg daily and Sotalol 40 mg bid Coreg 25 mg bid
Coreg 25 mg 2x/day
Sotalol 40 mg bid (checked to not continue) Coreg 25 mg bid
1/22/2011
Sotalol 40 mg bid and Toprol XL 50 mg daily N/A N/A N/A
2/23/2011 None recorded
Sotalol 40 mg bid and Coreg 25 mg bid
Sotalol 40 mg bid and ToprolXL 50 mg daily
Toprol XL 50 mg daily and Sotalol 40 mg bid
3/23/2011
Toprol XL 100 mg daily
Toprol XL 100 mg daily
Retrospective medical record review 2-2012
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SD’s Medication ManagementSD’s Medication Management
Resolve Drug Therapy ProblemsResolve Drug Therapy Problems Discontinue Sotalol and Toprol XLDiscontinue Sotalol and Toprol XL Continue Coreg 25 mg twice dailyContinue Coreg 25 mg twice daily Communicate with cardiologistCommunicate with cardiologist Communicate with pharmacyCommunicate with pharmacy Wife educated about medicationsWife educated about medications
Assumes responsibility to assure medications set up Assumes responsibility to assure medications set up and taken correctly by patient.and taken correctly by patient.
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1 year pre-enrollment Charges= $520,000; Receipts= $90,000;
Inpatient:12; ED visits:7
Post-enrollmentCharges = $11,686 ; Receipts= $0.
Inpatient: 0; ED visits:3
Leng
th
of
Sta
y
• IP Admit • ED Visit
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Family Perspective Family Perspective
SD is not aware of the SD is not aware of the difference.difference.
Wife is both proud of her Wife is both proud of her accomplishment as a accomplishment as a caretaker and grateful caretaker and grateful that he is not in the that he is not in the hospital and ER so much.hospital and ER so much.
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Hospital EncountersHospital EncountersReadmissions within 30 daysReadmissions within 30 days1/2010 – 1/20111/2010 – 1/2011
SMS Dsch Date SMS Entity Sum of SMS Total Charges
Sum of SMS Total Payments
2/2/10 DCMH 25558 9298 3/29/10 DCMH 49112 2322 4/10/10 DCMH 56778.6 9292 4/26/10 DCMH 29808 9298 7/9/10 DCMH 49979 6227
7/12/10 DCMH 24094 4014 7/24/10 DCMH 21744 5800 7/29/10 DCMH 25032 7843 8/18/10 DCMH 17756.8 2900
10/17/10 DCMH 43201 7840 10/23/10 DCMH 21691 10743 11/24/10 DCMH 37534 7843
TOTAL Admissions in 2010 12 402,287 83,460
TOTAL Readmissions within 30 days
6
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Now and FutureNow and Future
Prepared Office Visits Team approach
SD and his wife Physician seeing SD RN reviews diabetes Pharmacist med review
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Case of CB: “Why is she here so much?”
CB seemed to be in office waiting room every week—well dressed, friendly, no apparent distress
We reviewed the chart—multiple ER visits and brain CTs over past 2 years
Who is she?
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Meet CB
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Meet CB
60yo AAF Youngest of 5 children; identical twin Grew up in Philadelphia home with marital discord,
high levels of family conflict Physically abusive first marriage; strong second
marriage for past 24 years Has 3 adult children, many grandchildren On Social Security disability for chronic pain Works part-time as a hospital chaplain Currently working on second MA in theology
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Family History
Mother - died at 53 y/o from DM complications
Father - died at 62 y/o from CAD, h/o stomach cancer with mets
Twin sister – BRCA gene positive
2 brothers - one died from suicide, other brother died from drug and etoh abuse
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PMH
Anxiety/depression Fibromyalgia HTN CVA-1995 TIA Nephrolithiasis- 2009 PUD, GERD Diverticulosis MVA -2011
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PSH
Hysterectomy, oopherectomy ('89) Bilateral Mastectomy with breast
reconstruction ('00) - precancerous lesion in nodes and twin sister with BRCA
Cholecystectomy
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CB as a Super-Utilizer
5/5/2009: patient first presents to CFH for primary care
Patient with multiple ER visits prior to presentation to CFH for care for various complaints
Patient first identified as a super-utilizer on 8/22/11 Around this time patient was in ER/admitted multiple times
for syncope/gait imbalance and was complaining of memory issues, often forgetting her CFH appointments
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CB as a Super-Utilizer
Methods: Electronic medical records from 1996-present reviewed Date of ER visit, Diagnosis, Disposition recorded
-Radiology files in net-access reviewed for type and number of CT scans
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How many ER Visits has CB had since 1996?
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Answer- 102 ER visits!
Let’s break it down…
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Year Number of ER visits
1996 2
1997 2
1998 0
1999 0
2000 0
2001 13
2002 6
2003 7
2004 1
2005 1
2007 9
2008 21
2009 21
2010 15
2011 11
2012 4
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ER visits broken down by reason…2009: 21 visitsDate (visits since 5/5/09) Adm/ER Reason Other
5/18/2009 ER Urticaria
5/19/2009 ER Urticaria
6/2/2009 Admit Chest pain
6/5/2009 ER Nephrolithiasis
6/7/2009 ER Nephrolithiasis
8/3/2009 Admit r/o CVA CT head
8/16/2009 ER Arm strain
8/19/2009 ER Arm pain
10/11/2009 ER Head injury CT head
10/12/2009 ER Headache
10/20/2009 ER Abscess forehead
10/24/2009 ER Abscess forehead
11/10/2009 ER Folliculitis
12/8/2009 ER Fall
12/14/2009 ER Flank pain
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ER Visit breakdown: 201015 visitsDate Adm/ER Reason Other
1/2/2010 ER HA/HTN
1/29/2010 ER Hand contusion Fall
3/2/2010 ER Flank/abdominal pain
3/6/2010 ER Angioedema Allergic to cipro Rx
3/14/2010 ER AMS/slurred speech CT head
4/26/2010 ER Shingles
5/13/2010 ER Foot contusion Fall
6/7/2010 ER Headache, HTN CT head
6/27/2010 ER Urinary Retention
6/28/2010 ER Urinary Retention
7/1/2010 ER Urinary Retention
7/15/2010 ER Rash
9/8/2010 Admit Arm pain/elevated CK CT head -slurred speech, L weakness
11/22/2010 ER HTN CT head
11/24/2010 ER Head injury CT head
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ER Visit Breakdown: 201111 visitsDate Adm/ER Reason Other
1/18/2011 ER Hematuria Left before visit completed
1/31/2011 ER Knee contusion Dilaudid, Rx vicodin
3/23/2011 ER Headache CT head
4/27/2011 ER Lumbar/cervical strain
5/2/2011 ER Cervical strain
7/19/2011 ER Syncope CT head
8/19/2011 ER Angioedema
8/21/2011 Admit Angioedema/?CVA CT head
8/28/2011 ER Head injury CT head
8/29/2011 ER Contusion shoulder Dilaudid
10/18/2011 ER Angioedema Allergic reaction to grape
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ER visits 2012
2/8/12- admit 24 hour observation for chest pain and palpitations
3/10/12—lower leg contusion 4/28/12—cough 7/10/12—post-traumatic headache; had head CT
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How many CT scans has CB had since 1996?
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Answer- 113 CT scans!
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CT scans since 1996
72 CT head scans 31 CT abdomen/pelvis 3 CT chest 2 CT cervical spine 2 CT coronal/sagital/oblique 1 CT soft tissue of neck 1 CT thorax 1 CT lumbar spine
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The Makings of a Super-Utilizer
Personal and family histories of serious medical problems
Patient unable to distinguish routine from life-threatening medical problems
Husband: encourages ER use to decrease pt’s anxiety; he has own neurological issues
Patient tends to strongly suppress negative emotions and then experience distress somatically
Lack of PCP continuity
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Lack of Continuity of Care
1st office visit May 5th 2009 18 office visits at CFH in 2009
Saw 11 different providers in 2009 Saw one provider 6 times (Borgia)
16 office visits at CFH in 2010 Saw 11 different providers Saw one provider 3 times (Yun)
18 office visits at CFH in 2011 Saw 11 different providers Saw one provider 4 times (previous PCP Colterelli)
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Interventions
Psychotherapy: first session with Barry Jacobs, Psy.D. on 5/11/2011
Ensure consistent primary physician: Laura Finocchio MD, current PCP, has first office visit with patient on 7/28/2011, becomes PCP 8/22/2011
Neuropsychology Evaluation with Andrew J. Borson, PhD on 10/31/2011
Psychiatric referral 8/12
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Neuropsychology Evaluation Results Difficulties with short-term visual and verbal memory
and poor processing speed Executive function intact, good verbal abilities Poor listening skills No Cortical or Subcortical dementia Dissociative or Histrionic-type personality Memory and organizational issues seem to be
related to psychological issues
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Meeting with CB and Husband Reviewed neuropsychological results Told her no evidence of underlying
neurological disease Said “stress” manifesting itself as somatic
(neurological) symptoms CB and husband agreed with findings Agreed to goals of decreasing stress and
decreasing ER visits
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Results Since Interventions
Reduced ER visits and hospitalizations Regular visits with one PCP Patient acknowledgment of impact of anxiety,
anger and family stressors on overall sense of wellness
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CB ER visits since Interventions (as of 2/12)
00.5
11.5
22.5
33.5
44.5
Identified as Superutilizer
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Lessons Learned and Work Ahead We failed patient lack of PCP continuity of
care, took us over 2 years to realize patient was a super-utilizer; lack of adequate behavioral health services initially
Our patient CB had many office visits for ER f/u and “sick” visits, but few preventative care, f/u general medical issue visits, and psychotherapy sessions
Closer coordination with ER and Radiology
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SU Fellowship
One year fellowship in which 2 fellows split time between the Camden Coalition and Crozer-Keystone outpatient practices
Supported by two-year, $175,000 Aetna Foundation grant
Goals: become “clinical champion” for the development of strategies and implementation of systems to address frequent utilization
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SU Fellowship (cont.)
Goals (cont.): Work in multi-disciplinary team Understand social determinants of healthcare
utilization Improve care coordination protocols Analyze data Apply knowledge gained to CKHS
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Keys to SU Operations
Clinical champions—often based in family medicine residencies
Motivated health system Rich electronic data base Interdisciplinary collaborative team Engaged primary care network and social
service community Outcome measures for utilization, costs,
patient and provider satisfaction
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Keys to SU Funding
Seed monies generally coming from health systems themselves
Brenner has attracted state and national funders, including CMS and Aetna Foundation
Difficult to sustain concerted efforts by collaborative teams without dedicated funding—despite fact that SU programs are intended to save money