“Super utilizers” account for a disproportionate number of emergency department (ED) visits and inpatient admissions. An analysis at Long Island Community Hospital (formerly Brookhaven Memorial Hospital Medical Center) showed that 62 patients with chronic obstructive pulmonary disease (COPD) accounted for 432 ED visits and 27 patients contributed to 71 COPD readmissions.
To reduce preventable visits and readmissions, and anticipate patient needs, Long Island Community Hospital initiated a multidisciplinary collaborative with weekly team meetings to encourage communication and address challenges. To start, psycho-social assessments were conducted by social workers. These assessments were key to the management phase as part of a structured care pathway. Staff and patients were educated on the benefits of Health Home enrollment as another means of treatment. Through visits to patient homes, key reasons for utilization were identified, and a home care assessment tool identified priority needs for patients.
Of the original super utilizers, 85% were engaged by the team, 70% were enrolled in a Health Home, and 75% are now connected to home care or other community resources. ED visits for COPD patients decreased by 46%, while inpatient admissions decreased by 40%. COPD readmissions were reduced by 32%.
For more information, contact Cynthia Ruf, Vice President, Marketing and Branding, Long Island Community Hospital, at email@example.com.