Unraveling the Mysteries and Extensive Needs of Emergency Department "Superutilizers"

After his heart attack in 2009, Troy Johnson, who suffers from type 2 diabetes mellitus (T2DM), came to frequent the hospitals in and around Camden, NJ. At 345 pounds, the 51-year-old maintenance worker had a history of not eating properly or exercising regularly; he later compounded his medical problems by stepping on a nail, which led to an infection that doctors were unable to bring under control.

Johnson had no health insurance. He took whatever medication he could afford sparingly to make it last, and he frequently ran out of bandages for his foot wound. The only way he could get any medical attention was to show up in the emergency department (ED), so he did. Records show that he visited often, about once every 3 months for up to 3 years.

A term has been coined for Johnson and patients like him: the “superutilizer.”¹ Pioneering work by Jeffrey Brenner, MD, founder and CEO of the Camden Coalition of Healthcare Providers and a 2013 MacArthur Fellow,^2,3 found ways to identify patients like Johnson, and then to reduce the frequency of their ED visits. It requires addressing not only their chronic conditions but also their inability to self-manage their health needs. For patients like Johnson, diabetes is a frequent conspirator in the struggle, but it’s not the only one.

Several years ago, Brenner’s work with superutilizers caught the attention of CMS, because these patients account for an oversized share of Medicaid spending. A July 2013 informational bulletin from Cindy Mann, director of CMS’ Center for Medicaid and Children’s Health Insurance Program Services, cites the uneven spending distribution: statistics at that time showed 5% of beneciaries accounted for 54% of spending, with the top 1% of the beneciaries accounting for 25% of the spending. Among this 1%, 83% have at least 3 chronic conditions, and 60% have 5 or more such conditions.¹

And yet, this utilization is not surprising. As Mann wrote, superutilizers are those with “complex, unaddressed health issues and a history of frequent encounters with healthcare providers.”¹ Their healthcare is highly uncoordinated and rarely occurs in the appropriate setting. Connecting these patients with primary care doctors, and getting them to seek preventive services—which will address their problems more effectively and at a lower cost—is a major objective of the Affordable Care Act (ACA). In that same 2013 memo, Mann noted that the Center for Medicare and Medicaid Innovation had awarded Cooper University Hospital in Camden $2.8 million “to expand the Camden Coalition superutilizer program to serve over 1200 patients, with an estimated 3-year savings of $6.2 million.”¹

For all his encounters with the healthcare system, Johnson’s story got worse before it got better. He lost more than 70 pounds, but his foot eventually had to be amputated. Along the way he developed eye and bladder problems, and his ability to care for himself diminished. ”I got in a stupor,” Johnson says. “I didn’t have a job, I was just sitting. Everything was coming down on me—God was picking on me.”

These “frequent fliers,” as they are also known, come in all shapes and sizes. As the CMS statistics show, they frequently suffer from multiple chronic conditions, which can include substance abuse or mental health problems. Many have compounding social obstacles such as inadequate housing or lack of transportation. Many do not have health insurance, and even those who have obtained it for the rst time under the ACA may be unaccustomed to seeking care outside of the ED setting; many must be taught how to use insurance and find a primary care physician

THE EMERGENCY DEPARTMENT AS HAVEN

Some, in fact, seek out the ED; to them, it is like an oasis of warmth and attention. Doctors and nurses come to know them over time, and stable personal relationships develop, in contrast to the turmoil they may endure on the streets or at home, says Corey Waller, MD, director of the Spectrum Health Medical Group Center for Integrative Medicine in Michigan. The center uses a health team approach to address the needs of superutilizers in the hospital network.

“What happens is, you get patients who show up to the ED and they get food and something warm to drink, and an extra blanket and get treated almost like family; despite the ongoing trauma that the medical system levies on them with feelings of guilt and blame and unnecessary testing, it still is the only place that’s safe for them,” Waller said.

Spectrum Health’s system of 11 hospitals in Michigan’s Grand Rapids area have a 70% market share and until recently saw 1000 superutilizers visiting EDs 10 times or more each year, with each patient costing the system $55,000 on average, for a total of $55 million a year. With the creation of the Center for Integrative Medicine, efforts were made to work more closely with these high-cost patients, and their numbers dropped by half. “For some of our patients, we identify their issues, we stabilize them and get them into primary care; other ones have so many levels of complication that nobody feels comfortable with them, and so they stay within our clinic walls, and we see them as chronic patients,” he said.

PATIENTS WITH COMPLEX, DIFFICULT NEEDS

According to Brenner, addressing these patients successfully is as much a matter of nding them appropriate medical care as it is about reeducating them and attending to their complex psychological needs. The Camden Coalition of Healthcare Providers brings an array of medical resources and practical expertise to bear on the problem in this poverty-stricken New Jersey city. The coalition successfully worked with Johnson, the T2DM foot patient, to help him overcome transportation problems and map out a program of medical care that would keep him out of the ED. The coalition remains active with a patient for 90 to 120 days, teaching the patient how to function more independently. “The vast majority of people never go to the hospital except to be born and maybe once or twice in their lives,” says Brenner.

“Then there’s the 1% of the population that consumes almost 30% of the costs, because they go back to the hospital a lot. They’re very heterogeneous. If I said to you that all high utilizers are homeless, that would be wrong. If I said that all homeless are high utilizers, I’d be wrong. If I said that all high utilizers are diabetic, I’d be wrong. It’s the combination of all of these things.”

Indeed, a 2013 superutilizer summit co-sponsored by the Center for Health Care Strategies, a national nonprot, identied diabetes, mental health, substance abuse, and cardiovascular problems as among the most frequent issues among recurring ED users. Addressing those factors can be a handful for doctors or other healthcare providers, but for superutilizers acting on their own it’s almost impossible.⁴

“Let’s imagine you were just diabetic. That’s going to have a big impact on your life,” Brenner said. “But if I add hypertension and cholesterol, now you’re taking 7 pills a day, along with doctor visits. Let me throw in glaucoma, and now I’ll throw in doctor visits every month. Now let’s throw on top of that your hip’s bothering you, you can’t get around very well, and you’re using a cane, and let’s throw on top of that lack of family support and maybe you’re living on Social Security. Well, the whole thing is toppling over.”

EARLY LIFE TRAUMA A COMMON LINK

Brenner, Waller, and others working with high utilizers say that while T2DM and comorbidities certainly complicate the process of getting this population into effective treatment corridors, which would improve their lives while lowering the cost of care, the root of their problems are myriad traumas that many of these patients suffered in early life. Such problems contribute to both ineffective self-care and to self-destructive behavior, both of which must be addressed, providers say, before anything else can be fixed.

“The thing we have found all over the country is that the really extreme, often intractable, patients often have very high levels of early life trauma—the death of a parent, physical abuse, sexual abuse, one parent hitting another,” Brenner shared. “It’s had a very foundational impact on them. They don’t form trusting relationships very easily. Their reaction to stress is often quite different. They’re very disproportionally represented among frequently hospitalized patients.” Waller says 90% or more of the superutilizers in his system admit to early life trauma, which he calls “pretty disturbing.”

“Trauma leads to predictable behaviors—chronic anxiety, desire to escape, impulse control issues—somebody who needs an answer right now,” Waller said. “We nd that the only one that is consistently there for them is the healthcare system, not their neighbors, not their church, not their family, not their signicant other, not their kids. When we asked them ‘Where do you go if you need help with anything’? it’s the hospital, because they know that it’s there, and they know that people will be nice, and they know that they’re not going to be at risk.” As a result, much of the work done by specialists at the programs run by Brenner and Waller is designed to address the psychological barriers to changing lifestyles and following treatment plans.

OTHER TYPES OF HIGH UTILIZERS

There are other classes of the superutilizer. In Alaska, Medicaid Division of Health Care Services director Margaret Brodie encounters young mothers who bring their children to the ED because they overreact to medical problems or don’t have other alternatives, while other children turn up repeatedly after suffering from abuse. There are “pre-superutilizers” who come in the form of unborn babies whose mothers have substance abuse disorders, says Waller. Right out of the womb, these babies end up in neonatal intensive care units at a cost of more than $5000 a day. At Spectrum Health, treatment of this group starts during pregnancy with behavioral therapy for the mother and identication of social barriers to successful behavior.

In the University of Florida health system in Gainesville, hospital administrators found that patients were ocking to the ED from surrounding counties because effective charity care was unavailable. The 2 clinics in town accepted ony in-county residents and limited the number of cases each month. The solution, health workers said, was to establish a clinic alongside the ED that would address this supplementary need for care as well as the high utilizer population. “People come to our area from other areas because they cannot get help,” says Jacqui Pinkney, MSW, a clinical social worker at the UF Health Shands Care One Clinic in Gainesville. “We see that a lot because there are a lot of small counties that are between us and Tampa. I’ve had patients say that ‘I moved to this area because I couldn’t get help for this problem.’”

Winning trust from high utilizers so that they are willing to work with providers is key to the process, as many patients are distrustful and uncooperative. Participation in the Care One Clinic is voluntary, says Deepa Borde, MD, medical director. “We have found that trying to enroll patients in our clinic when they are not ready and not interested ends up wasting resources, and so we do our best to be present and available and to continue to speak with these patients and try to gain their trust.”

This can be a frustrating process, because when things don’t work out, clinic staff end up learning that resources would have been better spent on a more willing patient. “You keep scheduling these patients, but they don’t show up,” Borde said. “And then you can make calls in an emergency setting and you make another appointment, and they don’t show up again, and they keep not showing and they’re in your database and you’re not impacting them. I guess it’s a real life look at what can happen when you’re trying to help frequent visitors. But at the same time, why aren’t we saving this time by putting another patient in that slot?”

Much success has been achieved by going to the patient’s bedside upon hospital admission and introducing the Care One program to the patient to directly address their patient’s questions and concerns. Patients respond to this approach with greater interest, Borde said. From November 2012 to January 2014, UF Health Shands achieved a 30% reduction in ED visits among patients who entered Care One. Hospitalizations among those patients were reduced by 25%. High utilizers were identied as having visited the ED more than 4 times in the 6 months prior to visiting Care One. The gains were recorded in the 6 months following first contact with Care One.

BUILDING RELATIONSHIPS; PUTTING PATIENTS FIRST

The Alaskan Medicaid ofce instituted a statewide program in December 2014 to reduce the superutilizer drain on ED resources. Brodie said the health solutions company MedExpert was given the contract to bring about a mixture of case management and “soft” relationship work to effect change. In 2013, 3% of Alaska Medicaid users accounted for 22% of all ED Medicaid expenses, Brodie said. In particular, problems were noted in the Mountain View neighborhood of Anchorage, where a large proportion of residents earn low wages, and lacking transportation, stop at the only health facility on the local bus route: Alaska Regional Hospital.

Among Medicaid frequent flyers, “Almost half of them came from the Mountain View area,” visiting the ED 5 or more times in an 18-month period, Brodie said. This program is also completely voluntary, as at UF Health, Brodie said in mid-January. “And so far it’s working out pretty well. They’ve gotten well over 500 volunteers and it hasn’t been 3 weeks yet. And recipents report things like, “‘Boy, somebody nally cares about me!’”

The program is something of a sea change for the general Alaskan population, Brodie said, but in part of Alaska the soft approach has been successfully used via the native-run Southcentral Foundation Nuka System of Care. Since the late 1990s Nuka has sought to improve outcomes among high utilizers and others by offering a sense of ownership and ersonalized attention, according to Douglas Eby, MD, vice president of medical services for Southcentral.

“We believe the customer-owner (patient) is in control of their own journey and we are there to help support it by cheerleading and helping them become more and more self-care capable and family care capable over time,” he said. “What can we connect to that already exists inside of them that will help them make healthier choices and decisions?” The Nuka system operates on the philosophy that the medical system has in some sense failed its neediest patients by placing resources beyond their grasp or by treating them with mechanical indifference, Eby said, echoing a sentiment also expressed by Brenner of Camden. “We have really damaged adults standing in front of us who were victims of physical and sexual abuse as kids, who are visiting the hospital over and over, and we’re badgering them to take more personal responsibility. I mean, something seems really off about that,” Brenner said.

A core element of the Nuka plan, which has been widely replicated by CareOregon and has attracted worldwide interest, is a team approach that begins with a case manager being assigned

to a patient, draws in a team of health workers matched to the patient’s needs, and leads to the development of a “wellness plan” for each patient’s improvement, according to clinical social worker Melissa Merrick, director of Brief Intervention Services with Southcentral. This can produce rapid or slow results or none at all, depending on the patient, she said.

One frequent ED user tended to demand services he didn’t need and would fail to show up for appointments. He also tended to switch providers frequently, as patients are allowed to do in the Nuka system. This sent healthcare workers back to the starting point again and again. “This individual would become fairly defensive and argumentative and was fairly challenging to work with. We put a limit on the providers he could move to. It kind of forced him to start addressing some of the issues. He still can be argumentative and be difficult to have conversations with, but he’s actually engaging in services,” Merrick said. Now, he’s off pain medication and is exercising more and is less argumentative, she said. But the process took years. A more successful case was a 74-year-old female cancer patient who also suffered from alcoholism and obesity.

She “really embraced the services,” Merrick said. “We developed a plan for her to attend a cancer support group monthly and meet with a dietician twice a month. She lost 50 pounds and no longer drinks.” She’s also developing stronger, more effective relationships with her adult children, whom she is now holding accountable for their actions. “She’s very much a poster child for utilizing the system and all of the resources that are available to her,” Merrick said.

REFERENCES

1. Mann C. Targeting Medicaid superutilizers to decrease costs and improve quality. CMS Informational Bulletin. CMS website. http://www.medicaid.gov/federal-policy-guidance/down-loads/CIB-07-24-2013.pdf. Published July 24, 2013. Accessed February 5, 2015.

2. How hot-spotting cut healthcare costs by 50%. Robert Wood Johnson Foundation website. http://www.rwjf.org/en/about-rwjf/newsroom/features-and-articles/Brenner11.html. Accessed February 5, 2015.

3. MacArthur Fellows Class of 2013, Jeffrey Brenner. MacArthur Foundation website. http://www.macfound.org/fellows/886/. Updated January 12, 2015. Accessed February 5, 2015.

4. Hasselman D. Superutilizer summit: common themes from innovative complex care management programs. Robert Wood Johnson Foundation website. http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf407990. Published October 2013. Accessed February 5, 2015.