Many hospital personnel know those patients who always
seem to be in and out of the emergency department (ED).
Despite their best efforts to stabilize the patients and
educate them on their conditions, these patients always
come back in the same condition or worse. Personnel may
forget – or may not know – that patient A can't
refrigerate his medicine because he can't afford to pay
his electricity bill or that patient B can't make it to
her dialysis appointments because her car broke down.
These patients are often called
“super-utilizers” and can account for
an inordinate share of healthcare service use and
spending. For example, according to the
Alaska Division of Public Health, at least 110,942
unique patients visited an ED in Alaska in 2016 at a cost
of $621,576,853. While 64.6% of patients only visited the
ED once, 6% of patients visited the ED five or more times
that year. This 6% of patients accounted for 23.8% of the
billed charges, or $148 million.
The 2016 Center for Health Care Strategies, Inc. document
Accountable Care Organizations: Looking Back and Moving
Forward suggests that ACOs can address
super-utilizers' needs and thus reduce costs through
connections outside of the healthcare facilities:
“Given that the drivers of these patients'
health needs often go beyond physical health, ACOs are
developing partnerships with behavioral health providers,
social service agencies, and other community-based
organizations to address the social determinants of
health as well.”
Three ACOs across rural America share their stories of
improving care for their super-utilizers.
Melissa Hodge, Clinical Care Coordinator at ACHS, and
Sally Crossley, Clinical Manager, explained that joining
an ACO allows better communication among facilities.
Before joining, the members typically did not share
patient information and did not understand other members'
processes. Now, Hodge and Crossley said, “We
have routine meetings to discuss processes, identify
potential areas for improvement, and have very good
communication and sharing of ideas across
facilities.” Sharing data also allows the ACO
members to identify super-utilizing patients and
solutions to improve their care.
The Mountain West ACO consists of healthcare facilities
in 11 Montana and Idaho communities. The ACO offers
support for programs like chronic care management and
Medicare annual wellness visits that the members can then
offer to their Medicare patients.
Gritman Medical Center in Moscow, Idaho, is in the
process of implementing transitional care management,
which helps patients in the first 30 days after they're
discharged from the hospital. Staff members help patients
schedule and keep follow-up appointments and connect them
to other services with the goal to reduce readmissions.
Before joining the Mountain West ACO in 2016, Gritman
Medical Center and its clinics weren't routinely offering
these services to Medicare patients. Marisa Gillaspie
Aziz, Assistant CNO of Gritman Medical Center, explained,
“You don't have to be in an ACO to offer these
programs, but one benefit of being in an ACO is the
resources, structure, and support to effectively
implement programs that positively impact patients and
In 2011, UnityPoint Health – Fort Dodge in Iowa was
selected to participate in CMS's
Pioneer ACO Model. In 2016, UnityPoint Health's
Pioneer ACO joined CMS's
Next Generation ACO Model program at the same time it
became part of UnityPoint Health's overall ACO,
UnityPoint Accountable Care (UAC). Jennifer Crimmins,
Executive Director of UnityPoint at Home, said,
“The ACO has just been a catalyst for care
coordination. Before the ACO model, we knew that we had
partners that existed, but we didn't call on one
When the New Hampshire Rural ACO identifies
super-utilizers, these patients meet with clinical care
coordinators like Hodge of ACHS. The coordinator
identifies any barriers like affordability of
medications, housing, transportation issues, and lack of
access to healthy food. The coordinator then works with
those who can help address those barriers, like a primary
care provider, patient navigators, behavioral health
providers, dental providers, CHWs, and other agencies
like home health.
When the coordinator and other members of the healthcare
team meet with the patient, usually multiple times, to
address the barriers to healthcare, the team builds a
trusting relationship with that patient. Hodge and
Crossley explained, “Patients are then more
likely to be truthful with us and more likely to follow
directions because they feel truly cared for as an
Among other initiatives, the New Hampshire Rural ACO
focuses on medication reconciliation to reduce
readmissions and costs. In medication reconciliation, the
clinical care coordinator meets with patients to make
sure each patient has the correct medications, is taking
the correct dosage, has no allergies to the medication,
and understands instructions.
ACHS's 30-day readmission rate for Medicare patients who
received transitional care management services within the
last four months is only 5.7%.
Patients' Success Stories #1: New Hampshire
One patient had a history of uncontrolled diabetes,
chronic pain, PTSD, depression, adrenal insufficiency,
and a heart transplant. This patient was a top
super-utilizer, with 22 emergency department (ED)
visits in one year. Through chronic care management
(CCM), this patient lowered A1c levels from 12.1 to
8.1, was referred for pain management, and had only one
ED visit in the following year.
Another patient had a history of poorly controlled
asthma, depression, anxiety, and tobacco use. Through
CCM, this patient went from smoking one pack a day to
one cigarette a day and is now managing his/her
depression and anxiety symptoms through pharmacological
and non-pharmacological methods.
As part of its participation in the Mountain West ACO,
Gritman has launched a Chronic Care Management (CCM)
program staffed by a population health nurse. This
program connects patients in need with transportation
services and prescription assistance programs, supports
eligible patients with enrollment into programs like
Medicaid, and helps them become better informed of their
conditions and thus advocates for their own care.
“We're helping them get connected with the care
and resources they need, so patients can stay in their
own homes with better health and quality of
life,” said Gillaspie Aziz.
Gillaspie Aziz said that the CCM program – available for
patients with two or more chronic illnesses – was a great
way to start implementing these Medicare programs. While
it requires participation from the staff and providers as
well as patient engagement, Gillaspie Aziz called it
“a nurse-driven program.” When the
Mountain West ACO first launched, the nurses
“could use CCM to immediately start making a
positive impact for patients.”
In 2012, the UnityPoint Health – Fort Dodge Pioneer ACO
began work to reduce its readmission rates. Their staff
soon realized that this work couldn't take place solely
in the hospital, so they began partnering with ambulatory
and post-acute care communities and implementing an
electronic health record so these facilities can better
share patient data.
“Through that,” said Aaron McHone,
ACO Executive Sponsor of UnityPoint Health – Fort Dodge,
“we learned that patients aren't hospital
patients or clinic patients or home health patients or
nursing home patients…It didn't take long, once we got on
the shared medical record to realize that these are all
the same people – we're sharing these
UAC's leadership has decided that programs and services
that benefit Next Generation ACO patients will likely
benefit other patients as well. “We try not to
differentiate the way we provide care just by who the
payer of that contract is,” said Crimmins.
Patients' Success Stories #2: Mountain West
When a patient with dementia was admitted to the
hospital, the coordinator made arrangements with home
health, personal home caregivers, Meals on Wheels, and
prescription delivery so that this patient could return
home to his/her family upon discharge. Gillaspie Aziz
explained, “For patients with dementia, they
do much better in their own homes” than in an
unfamiliar setting like a nursing home or hospital.
“What the care coordinator does is they really
become that patient's advocate and make sure that patient
gets where they need to go, make sure the patient knows
what they need to do,” said Lynn Barr, CEO of
Caravan Health, which supports 38 ACOs, containing 250
hospitals, about 14,000 providers, and about 1 million
Medicare beneficiaries. Care coordinators are also there
for the patient if any questions or issues arise.
Advice from the ACOs
Barr from Caravan Health reminds rural healthcare
facilities not to outsource their care coordination:
“You can outsource care coordination and you
can bill a lot, but all you're doing is increasing the
cost of care.” Instead, she said, facilities
need to learn how to provide care coordination.
Ed Shanshala, CEO of ACHS (part of the New Hampshire
Rural ACO) recommends that other facilities looking to
improve their super-utilizers' health should first
understand their organization's purpose, focus on growing
relationships with patients and community resources,
refine processes to be effective and efficient, and then
produce excellent results.
Staff buy-in is also a key to success. Gillaspie Aziz
explained that implementing a program involves
“educating team members on the what,
the why, the how.” She now
sees a shift in the Mountain West primary care providers'
thinking as they increase their focus on population
health, for example, looking at ways to increase
mammogram and fall risk screening rates.
Gillaspie Aziz added that it's not enough to just offer
programs and services. Patients also need to know why the
service is important and how it will benefit them.
Promoting the Medicare annual wellness visit benefit, for
example, involves reminding patients that there's no
copay or deductible as well as explaining how the annual
wellness visit can help them improve their own health.
“Patients have to agree to participate in
chronic care management,” said Gillaspie Aziz.
“Patients have to be willing to come into the
office to complete their annual wellness
Barr explained that the only way to change patients'
behavior is by building a relationship with them. Rural
ACO facilities, located in small communities where
everyone knows everyone else, are at an advantage, as
staff members often already know their patients well.
“That's why people are in healthcare, to make a
difference,” said Gillaspie Aziz.
“Being able to show how these programs have
made a difference in the lives of patients is really
Patients' Success Stories #3: UnityPoint Health
– Fort Dodge Pioneer ACO
A patient came into the emergency department and needed
to be hospitalized. Staff learned that the patient's
home had a significant insect infestation. Just
treating and sending the patient home would cause
him/her to become hospitalized again, so staff knew
they would need to get rid of the infestation.
The staff of the UnityPoint Health – Fort Dodge
Pioneer ACO offered to set the patient up in long-term
care while the house was cleaned. The patient initially
refused, because his/her pets wouldn't be able to come
with. Staff called a local veterinarian, who agreed to
board the pets free of charge. “When the
patient knew the pets were taken care of,”
said McHone, “the patient was willing to
go.” The staff also helped the patient enroll
in Medicaid so he/she could afford long-term care.
Then came time to clean this patient's home. A dumpster
company donated a dumpster so that staff members could
throw out the infested furniture, and paramedics and
the county's public health department supplied personal
protective equipment. An exterminator volunteered to
spray this patient's home.
Once the house was clean, staff members connected the
patient with public health services so the house could
receive routine check-ups and avoid another
infestation. The public health department connected the
patient with consignment stores to refurnish the home.
The patient has not been readmitted to the hospital.
Allee Mead is a web writer for the Rural Health Information Hub. She has written on important rural issues, including maternal mortality and farmers' mental health, and has presented nationally on RHIhub's opioid resources. Originally from rural North Dakota, she has a master's degree in English. Full Biography