Superutilization Management
Shifting health care utilization for patients with complex needs
Opportunity
The Centers for Medicare and Medicaid Services (CMS) define superutilizers as patients who accumulate large numbers of emergency department (ED) visits and hospital admissions that could have been prevented by relatively inexpensive early interventions and primary care.
It is challenging to identify superutilizers in real-time, making it difficult to intervene.
Nationally, the top five percent of the population, ranked by health expenditure, accounts for nearly 50 percent of total health care costs. In 2015, 0.5 percent of patients at Penn Medicine's Family Medicine and Community Health practice accounted for 15 percent of ED utilization across the entire patient panel.
Intervention
The Superutilization Management Program (SMP) integrates patients who have a history of pursuing low-value, high-cost care into a supportive network that enables them to quickly and easily connect with providers to obtain the right level of care for their needs.
The program leverages an automated Agent dashboard to track superuitlizers and alert providers of activity in real-time. Populated with data from the electronic health record (EHR), care team members can view utilization patterns and care management activities on the dashboard, information that can be leveraged to risk-stratify patients and create tailored care plans anchored in primary care.
The program features a 24-hour hotline, weekly check-ins, and ongoing case reviews to keep the lines of communication open for patients. Coordinators from the SMP team also provide proactive appointment scheduling and transportation and social services support after ED visits or inpatient discharge to ensure smooth transitions between care settings.
Impact
During the initial pilot at Penn Medicine's Family Medicine and Community Health practice, the SMP model produced a 43 percent reduction in admissions, a 50 percent drop in readmissions, and a 13 percent decrease in no-shows to outpatient appointments.
Today, the program integrates with primary care-based behavioral health models, pharmacies, and home visit services and serves as the flagship program for the department's participation in the Centers for Medicare & Medicaid Services' Comprehensive Primary Care Plus model.