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

Purpose:

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.

Methods:

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.

Results:

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.

Implications:

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.