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Super-utilizers – Contemplating what counts

Holly Batal, MD Jeremy Long, MD Tracy Johnson, PhD, Josh Durfee, MSPH

Studying interventions to reduce costs and improve outcomes in super-utilizers is not easy. Not only are there differences in the definition of patients, but it is difficult to differentiate program effects from secular trends and regression to the mean due to lack of a randomized control group. Our study of super-utilizer interventions was part of a bigger primary care transformation project. We knew that to sustain the program we had to show some improvement/cost reduction for those patients that were highest risk/cost. We believe that our results show a way forward in evaluating these types of projects. Rather than relying on pre/post with the inherent concern of regression to the mean, we challenged ourselves to meet a higher standard, one of improving upon “usual” care. But the question remains, what is it that makes a difference? What is the intervention that really does reduce costs in super-utilizers?

We have struggled to package our intervention in a way that is replicable, not only for those outside our system, but for ourselves. However, could this lack of standardization be the key? Perhaps the ability to really focus on what is important for each patient is what truly matters in each situation? We often talk about personalized health care. We talk about patient engagement, and we talk about the need to set patient-centered goals. What is harder to capture is the intersection between what the health care team knows to be optimal medical care and what a patient has the capacity to do in that moment in their life. How to help the patient prioritize and work on the interventions, resources, and behavior changes will bring them the most value.

To exemplify our efforts, consider two homeless patients with alcoholic cirrhosis.  One is cared for by a health care team that is able to go outside the usual bounds of providing “just” health care. Because of this, he attains stable housing. The other patient remains homeless and vulnerable to climate, assault, and temptation.  The former improves one social determinant of health and is able to leverage this into more support for behavior change and, possibly, sobriety.  The latter remains at risk for worsening health or death amidst a tangled morass of homelessness and addiction.  Although both of these patients are high utilizers, one gains an easier path to better health while the other labors to achieve any positive change at all.  Both patients require team-based attention, care/case management, and an individualized care plan to provide the right amount of care.

So how do we define the critical elements? Care is the one that comes to mind first – that the patient not only understands but feels that we care about them, respect them as an individual, do not just them, and truly want to help them. This theme of respect is what comes through most strongly in our interviews with patients. They need to feel safe before they can engage with us to work on their complicated medical issues. Connection is important, helping patient to connect with the health care team when they need to, and to develop connections to multiple people on the health care team. A particular patient might be more comfortable being open and working with a non-physician team member. Then there are clinical skills. It goes without saying, but you need clinicians that are comfortable dealing with comorbidity and uncertainty. We have to collaborate. Not just with our patients, but with their caregivers and their community. We also have to collaborate and be tightly connected with the parts of the health care system that our patients touch often – the ED, the specialists, the ICU physicians, the hospitalists. Chance plays an important part as well. We have to be open to intervening when and where we can. Often this is in time of crises. We must have compassion. We cannot truly know what our patients have struggled with. But, we can walk besides them as they try to improve their health. The team must have consistency. Not just in terms of team composition and availability, but in having equanimity to deal with the highs and lows of working with a patient population that is going to continue to be ill, that is often going to continue to be high cost. The intent is not to avoid spending money on health care, the intent is to spend money in a way that will truly improve lives.

But ultimately what we need to have is courage. The courage to be willing to try and the courage to be willing to fail. The courage for honest evaluation of our programs’ strengths and weaknesses. The courage to keep moving forward to make things better and the courage to let go of things that aren’t successful. We hope our evaluation helps you to move forward to make your program better. We know that it has helped ours.

Holly Batal is from Mid-Atlantic Permanente Medical Group of Kaiser Permanente in Rockville, MD

Jeremy LongTracy Johnson and Josh Durfee are from Denver Health and Hospital Association in Denver, CO.

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