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.

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.

It is challenging to identify superutilizers in real time, making it difficult to intervene.  

Intervention

The Superutilization Management Program (SMP) integrates patients with 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 proper care for their needs.  

The program leverages an automated dashboard to track superutilizers. Populated with data from the electronic health record, the dashboard lends insight into utilization patterns and care management activities that can be leveraged to risk-stratify patients. It also alerts providers of activity in real-time so they can practively create tailored care plans for patients 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.