“Super utilizers,” individuals who account for a disproportionate number of emergency department (ED) visits and inpatient admissions, have underlying needs that often go unmet. Saint Joseph’s Medical Center in Yonkers identified these needs and improved care of the under-served after conducting an analysis in accordance with the Delivery System Reform Incentive Program (DSRIP).
The analysis revealed that regardless of the primary medical indication for admission, super utilizers had common social factors, such as the need for hemodialysis, mental and behavioral health services, or insurance. In response, Saint Joseph’s Medical Center implemented the following: a focused assessment to reveal underlying reasons for visits; a program in partnership with medical Health Home and the existing psychiatric care network; and process-specific algorithms for common care cohorts, such as hemodialysis. The team also strengthened collaboration with community organizations.
ED visits and inpatient admission/readmission for super utilizers decreased by 28% and 71%, respectively, while overall acute visits decreased by 37%. Engagement with the medical Health Home team increased by 36%.
For more information, contact Lisa Hanrahan, at firstname.lastname@example.org