Reducing emergency room use by targeting 'super utilizers'

Dr. Kari Alperovitz-Bichell, left, talks with patient Preston Holland, a resident of Morris Blum Senior Apartments, as he visits the Anne Arundel Medical Center community clinic that is located on the ground floor of his building.
Dr. Kari Alperovitz-Bichell, left, talks with patient Preston Holland, a resident of Morris Blum Senior Apartments, as he visits the Anne Arundel Medical Center community clinic that is located on the ground floor of his building. (Barbara Haddock Taylor / Baltimore Sun)

Matthew Hardy didn't know why he sometimes felt so sick, but the 28-year-old Park Heights resident felt bad enough that he would go to the emergency room, mostly at Sinai Hospital, often by ambulance.

He went eight times in a four-month period earlier this year.


"I didn't know what was going on with my health," he said.

Hardy was what's known in the medical community as a "super utilizer," someone who uses a disproportionate amount of care. In an effort to reduce costs and the burden on the system, hospitals and other medical care providers have begun targeting those patients who frequently tap emergency care by connecting them with resources to tackle underlying problems.


The potential health and financial implications are huge: Federal officials estimate that 5 percent of those using Medicaid, the health program for the poor recently expanded in Maryland and elsewhere, account for more than half of spending.

Sinai officials believe they have a promising model to keep people like Hardy healthy and out of the hospital. More than a year into a three-year, state-funded $800,000 pilot program, they've eliminated more than 1,000 emergency visits and earned back the investment.

They flagged about 318 people through electronic medical records who had emergency trips at least four times in four months and linked them to primary care doctors and insurance, as well as mental health and substance abuse programs, and often social services.

"People ignore their medical needs when they have other troubles," said Traci Kodeck, vice president of population health at HealthCare Access Maryland, a nonprofit group helping administer the grant.


The Sinai patients like Hardy were connected to a so-called care coordinator, who often would work with them for several months. Staff members not only make medical appointments, but line up transportation and meet them at the doctor's office. They scour community resources for extra food, help paying electricity bills, shelter from domestic abuse and even housing.

It takes some relationship building before people accept help, said Danielle Richards, one of three Sinai care coordinators, so "I'll meet people in a park if I have to."

Only about 10 percent made no progress, mostly those with behavioral health issues, officials said.

Hardy became a model after entering the program in April. He learned he had diabetes and high blood pressure, which ran in his family. He took medications for the chronic conditions, replaced some sodas and pizzas with salads and water and "stayed out of trouble." He lost stress and gained energy, which he used to care for his aging mother.

And he hasn't been back to the emergency room.

Many other programs in Maryland and nationally employ similar strategies targeting super utilizers, said Rachel Davis, a senior program officer at the Center for Health Care Strategies, which promotes such health programs and others.

Most programs have been around for only a couple of years and tend to target the poor, seniors and those with chronic medical and behavioral health conditions. They all line up insurance and doctors.

"But a lot of what these individuals do is outside of the medical setting," Davis said.

Many believe modern efforts to curb emergency room use stem in part from the work of Dr. Jeffrey Brenner, who won funding from the Robert Wood Johnson Foundation in 2005 after he identified the scope of the problem at a hospital in Camden, N.J. When he investigated the high emergency use of some patients, he found that 13 percent of patients accounted for 80 percent of hospital costs in the city.

The foundation helped fund a project that initially involved 36 patients. After intervention, their emergency room visits dropped to 37 a month from 62 and their hospital bill fell to $500,000 from $1.2 million. The foundation continues to fund Brenner's work and other programs.

Successful programs have common threads but also reflect their communities, said Susan Mende, a senior program officer at the foundation. Some address homeless veterans' mental health needs or adults suffering effects of trauma experienced in their youth.

Some rely on social workers or nurses, while others train police or former addicts.

"The models are not the same," Mende said. "But no one has to start from scratch."

Medical care providers in Maryland take several approaches.

Anne Arundel Medical Center in Annapolis opened a state-funded clinic in 2013 in a public high-rise for about 200 disabled seniors and the surrounding community. Officials had noticed many emergency patients came from 701 Glenwood St., which turned out to be the tower.

They investigated and found nine people were responsible for 41 percent of visits. Everyone had complex medical conditions, but some called ambulances when they were lonely or wanted a meal or even a pair of socks, said Dr. Patricia Czapp, chair of clinical integration at the medical center and a clinic doctor.

Among the seniors, there's been a 17 percent drop in emergency room visits, 40 percent drop in admissions and 75 percent drop in readmissions.

"They've been coming to the emergency room for decades and it worked; they'd get there and get love from the nurses," Czapp said. "We put love on the first floor of their building."

On the Eastern Shore, Dr. Joseph Ciotola Jr., the Queen Anne's County heath officer, aimed to cut 911 calls by sending uniformed paramedics to people's houses before they dialed.

Under his pilot program launched in 2014 with the University of Maryland Shore Regional Health system, Ciotola, also the medical director for the county's Department of Emergency Services, used call data to identify 14 people who had called at least five times in six months.

Most were seniors forgoing routine medical care because they were isolated and lonely. Calls to 911 dropped by 22 percent in the first year since those people were linked to care and services, including social outings.

The program has since added other people referred by first responders and doctors at Maryland's Shore Emergency Center.

"When paramedics made the calls, every single person answered," Ciotola said. "They were the key piece. People have a sense of confidence and security with 911 responders."

State emergency coordinators are now looking to expand the program outside the county.

At the University of Maryland Medical Center in downtown Baltimore, where emergency department officials identified many repeat patients with mental health and substance abuse issues, officials began employing case managers to connect them with appropriate community services at all times of the day.

Those patients also were able to quickly make appointments with system doctors and specialists who could manage their chronic health conditions.

Doctors also turned to a new statewide electronic medical records system to tell them when patients had recently visited other hospitals and what services were provided, so they could avoid repeating expensive and time-consuming work, said Dr. Michael Abraham, an emergency physician at the center.


"I can grab a social worker and go over and see what they really need, but most of the time they don't need another medical work-up," said Abraham, also an assistant professor of emergency medicine in the university's School of Medicine. "That makes it easier in a busy emergency department."


The efforts began in earnest 12-18 months ago, he said, and he's noticed fewer familiar faces.

Abraham said most hospitals now seem to have some program, and he and others noted particular urgency in Maryland, where the state has a unique agreement with federal regulators to control growth in health care spending. Hospitals recently agreed to strict budgets.

In the past, super utilizers meant more money and no one had a financial incentive to change, said Amy Perry, president of Sinai Hospital and executive vice president of LifeBridge Health.

Hospitals collected insurance for treating the same maladies and would offset patients who couldn't pay by charging everyone else more. But hospitals in Maryland now reap savings for coming in under budget, incentivizing them to keep people healthy and out of the hospital.

"That's about the biggest win-win project we can be involved in," Perry said. "This is the right way to provide health care."