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Super-Utilizer Pilot Project

  • Need: To address patients' complex physical, behavioral, and social health needs with the goal to reduce unnecessary visits to the emergency department and reduce inpatient admissions.
  • Intervention: A registered nurse and community health worker use technology to address patients with high risk and high costs in their home setting through a 90-day intensive intervention.
  • Results: The healthcare team in Kalispell saved more than $1.8 million in hospital costs with the project's first 36 patients.


A pilot project in Billings and the rural communities of Helena and Kalispell, Montana, addresses the needs of high-risk patients in order to prevent unnecessary hospitalizations and emergency department (ED) visits.

In the Super-Utilizer Pilot Project, community health workers (CHWs) and registered nurses (RNs) identify and help address factors leading to cyclical inpatient admissions and ED utilization. In addition to physical health, this project addresses mental health, substance use disorders, and social determinants of health like housing, transportation, health literacy, and social isolation.

The pilot project operates in conjunction with health system and community partners in all three locations. It is funded by the Robert Wood Johnson Foundation (RWJF) and the Centers for Medicare and Medicaid Services (CMS).


Services offered

Patients who visit the ED multiple times or are admitted as inpatients at least twice in a six-month period are identified as "super-utilizers." In addition, patients who have ambulatory-sensitive conditions like high blood pressure or diabetes would benefit from this model and additional primary care extended support. Thirty to 90 days after super-utilizers are discharged from the hospital, CHWs and RNs perform the following activities:

  • Travel to patients' homes to identify any barriers to health or healthcare
  • Coordinate community resources such as rides to appointments
  • Build plans of care for better collaboration across healthcare and social service providers
  • Build trusting relationships with patients
  • Join patients during appointments as "medical mediators"
  • Participate in patient support group telephone conferences


With the project's first 36 patients, the Kalispell team has saved more than $1.8 million in hospital costs.

The project was featured in a 2017 PBS NewsHour story. In this story, one patient reported that her Medicare costs went from $100,000 in a six-month period (when she was living in her car) to less than $6,000 in a seven-month period after she found affordable housing.

Project coordinators have presented their work for CMS and events like the Transitions of Care Summit. The Super-Utilizer Pilot Project is also a 2017 American Hospital Association (AHA) Case Study.

For more information, you can read or view the following:


  • Montana currently does not have a state training or certification process for CHWs.
  • Systems-level gaps exist at the community level, such as affordable housing and transportation.
  • Various hospital legal teams had different electronic health records and different interpretations for subcontracting and data sharing agreements.
  • At first, community partners worried about competition with the other partners, so they first needed to build communication, rapport, and trust. Partners also had no established policies or protocols and had to modify assessment tools.
  • Nurses had not been trained in this type of work, but nursing schools are currently building curriculum around care coordination. Nurses received initial training online through the University of Pennsylvania School of Nursing.
  • Most care models were built and tested in urban settings.
  • There is a large geographic area for the small teams to cover.


  • Evaluate your community's needs and see what assets and programs are already in place.
  • Don't overanalyze the data. Start with one patient and see what it would take to start a similar program.
  • If you use iPads in your program, make sure they are cellular-enabled instead of relying on home internet connections.

Mountain-Pacific Quality Health's website also offers resources such as literature and tools to help you start a similar project. More information is available through the following resources:

Contact Information

Colleen Roylance, Chief Operations Officer
Mountain-Pacific Quality Health
ReSource Team

Care coordination
Community health workers
Social determinants of health

States served

Date added
November 6, 2017

Date updated or reviewed
November 1, 2019

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.