Sustainable High-Utilization Team Model

CSHP is advancing a national model of care to improve care and lower costs. Funded by the Health Care Innovation Award, an Affordable Care Act (ACA) health care reform initiative, the model uses “hot spot” data analysis to identify and redirect over 2,500 high utilizers of preventable hospital services to care that is more appropriate and less costly. Patient chronic care needs are managed more effectively and at less cost than hospital-based care, saving a projected $67.7 million over three years. The project builds on an innovative care model from Camden, New Jersey, and is being implemented in four clinical sites around the country: Allentown, Pennsylvania; Aurora, Colorado; Kansas City, Missouri; and San Diego, California. Key elements of the model include: Development of “hot spot” data and analysis in order to identify high utilizers (e.g., patients with two or more inpatient stays in six months) and outreach and referral of patients to care teams; Nurse-led care management teams that include social workers and community health workers. The team approach helps patients better manage their chronic conditions by helping them consistently fill prescriptions, understand how they can help manage their own conditions, and stabilize their housing, income support, and other needs; After patients are stabilized, the care management teams will transition them to local primary care medical homes that provide ongoing care. Savings will be generated as the projects improve patients’ access to ambulatory medical and social services, achieve improved patient outcomes, and reduce preventable inpatient and emergency department utilization.