Nationally, the top 5% of the population, ranked by health expenditure, account for nearly 50% of total health care costs.
In 2015, 0.5% of patients at the Penn Family Medicine and Community Health practice accounted for 15% of emergency department (ED) utilization across the patient panel.
Much of the utilization of low-value, high-cost care is driven by unmet social needs and poor access to primary and behavioral health care. Also, it is challenging to identify "superutilizers" in real-time, making it difficult to intervene.
In partnership with a multidisciplinary group led by Anna Doubeni, MD, MPH, we worked with the Agent team to develop technology to proactively identify "superutilizers" in the Penn Family Medicine and Community Health practice so that interventions to reduce unnecessary utilization could be tested.
The platform is designed to track utilization patterns and drivers as well as care management activities in an automated web-based dashboard linked to the electronic health record (EHR).
Leveraging data from the dashboard, the team is able to risk-stratify patients with complex medical and social needs and empower them to receive care anchored with their primary care provider.
For patients with complex needs, the Superutilization Management Program (SMP) offers tailored interventions such as transportation services and social service supports.
The program features a 24-hour hotline, weekly check-ins, and ongoing case reviews to keep the lines of communication open with patients.
To ensure smooth transitions, a care coordinator from the SMP team provides proactive appointment scheduling after ED visits or inpatient discharge.
Initial analyses showed a reduction of 43% in admissions, 50% in readmissions, and 13% in no-shows to outpatient appointments at the Penn Family Medicine and Community Health practice following the introduction of the SMP.
In its current state, the program integrates with primary care-based behavioral health models, pharmacies, and home visit services, and serves as the flagship program for the department’s participation in the Centers for Medicare & Medicaid Services' Comprehensive Primary Care Plus (CPC+) model.