Filling the Gaps: How “Super Utilizers” Received Care through a Hospital-School of Nursing Partnership

Saturday, 7 November 2015

Della J. Anderson, MSN, MBA, RN
Baker University School of Nursing, Topeka, KS, USA


Our Emergency Department (ED) was experiencing increased visits by a patient population referred to as “Super Utilizers.” The Continuum of Care department recognized an opportunity for innovative collaboration with the Emergency Department (ED) and an affiliated School of Nursing. A zero cost model program was created using Camden Model/Spectrum Health/Colorado Mental Health Model of Care as the basis. We determined these patients returned because of challenges in access to a primary care; inability to pay for healthcare services; lack of health education; or desire for social interaction. Most ED patients do not return after treatment. However, these patients received repetitive care that often included costly testing.


By partnering with the school, students became health coaches to assist with “gaps” in care. Student pairs were assigned one patient and a prepaid telephone for 24/7 access; then given medical history, information about community resources and health insurance/benefits to provide support. The ED notified students when a patient visited and follow-up was completed in the ED or by telephone the next day. Students proactively contacted the patient to discuss appropriate ED usage, emotional support, and follow-up care.


The initial program assisted 21 patients who had made 710 visits and total patient charges of $2.45 million during the previous year. Program results projected a decrease to 510 visits and total charges of $1.76 million annually.


This unique partnership meant “Super Utilizers” received a more appropriate level of care, students received hands-on health management training, and the ED experienced a decrease in non-emergent visits.

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