Session #D4a
October 6, 2012
Implementing Brenner’s Collaborative
Super-Utilizer Model
Barry J. Jacobs, Psy.D., William Warning, MD,
Steven Sluck, DO, Stephanie Maruca Watkins,
DO
Crozer-Keystone Family Medicine Residency
Program—Springfield, PA
Collaborative Family Healthcare Association 14th Annual Conference
October 4-6, 2012 Austin, Texas U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Objectives
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Describe the Brenner Collaborative SuperUtilizer Model using research data to
demonstrate its efficacy for improving clinical
outcomes and reduce healthcare costs
Illustrate a successful implementation
through presentations of two case studies
Identify key operational and training
components for effective collaborative superutilizer teams
Learning Assessment
A learning assessment is required for CE credit.
Attention Presenters:
Please incorporate audience interaction through a
brief Question & Answer period during or at the
conclusion of your presentation.
This component MUST be done in lieu of a written
pre- or post-test based on your learning objectives to satisfy
accreditation requirements.
Today’s Talk
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The crucial issue of utilization in today’s
healthcare
What is a “super-utilizer”?
What are the elements of an SU program
using collaborative team interventions?
Case of SD, a hospital SU
Case of CB, an ER SU
SU Fellowship
Keys to SU operations and funding
High Utilization Driving Healthcare Costs
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Premise: Our most medically and
psychosocially complex patients use
disproportionate amounts of healthcare
resources
Drive up total healthcare costs
1%
5%
10%
$90,061
22%
$40,682
50%
$26,767
50%
65%
$7,978
97%
U.S. Population
Health Expenditures
Distribution of Health Care Expenditures for the U.S.
Population, According to Magnitude of Expenditure, 2009
The sickest 10% of patients account for 65% of the health care
expenses. Dollar amounts are annual mean expenditures per
patient. Data from the 2009 Medical Expenditure Panel
Survey, adapted from the Commonwealth Fund.
What is a “High-” or “Super-Utilizer”?
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Well researched, well defined problem with a
few successes.
4 Major Studies were reviewed
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2010 Mount Sinai School of Medicine
2009 Midwestern Urban Hospital
2009 Camden Coalition of Healthcare Providers
2006 IOM Report
Characteristics of High-Utilizers
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Most are insured, 60% public insurance
Only 15% uninsured
Over 80% have identifiable PCPs
More utilization of health services in general
Diagnoses vary greatly
Ages 25-44 and over 65
Addiction and mental health issues make it more
difficult for patients to navigate system
Usage Patterns
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High utilizers use the ED >3x per year
5-8% of ED patients account for 21-28% of
visits
Over 50% sought care at 2 or more EDs
70% of frequent visits were on evening or
night shift
Who is Jeff Brenner, MD
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Frustrated family MD
Closed solo practice in
Camden, NJ
Began looking at data
about city’s healthcare
trends
Brenner (cont.)
The Camden Study-An ED Alternative
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5 year study of 380,000 visits at 3 EDs
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1% of patients 40,000 visits, $46 million
cost
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Top 35 utilizers generated $1.2 million in
charges each month
Brenner (cont.)
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Formed Camden Coalition of Healthcare
Providers in 2002
Developed Camden Healthcare Database
Formed relationships with outpatient and
inpatient providers, as well as social service
agencies, throughout city and state
Promulgated “hot-spotting” or “super-utilizer”
model of collaborative intervention
Components of SU Interventions
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Data mining (sometimes across health systems and
agencies) to create SU list
Creation of collaborative multi-disciplinary teams:
physicians/nurses practitioners, case managers,
social workers, mental health consultants, health
educators
Assessment procedures and outcome measures
Relationship-building with other healthcare and
social service providers to improve care transitions
and marshal community resources
The Camden Study
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35 highest utilizers were put into Camden Coalition
Project
Social Worker, CRNP, Case Managers, Health
Educators, cost $300,000/yr
35 patients received individualized case
management services via the Coalition
Monthly charges reduced from $1.2 million to
$531,000
For every $1 spent $1.44 was saved in hospital
costs
Who are we?
Crozer-Keystone Health System
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5-hospital health system, with 6800 employees, in
western suburb of Philadelphia
Delaware County: pop. of 550,000;
socioeconomically and culturally diverse; inner ring,
decaying suburbs and more middle-class
neighborhoods
Residency: 9-9-9 program, founded in 1994; two
family health centers; one an FQHC
Two fellowship programs (SU and sports medicine)
Clinical affiliation with Temple University School of
Medicine
Timeline of Our SU Project
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Pilot initiated in summer of 2011
Joined FMEC SU Learning Community
Feb. 2012: SU presentation to health system’s
administrators by Jeff Brenner; SU team presented
two cases
Led to health system initiating High Utilizer Program
At that presentation, announcement of SU
Fellowship, co-sponsored by Crozer and Cooper
Health System in New Jersey
Our SU Team (with Dr. Brenner)
SU Team Activities/Outcomes
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Graduated one of pilot cases; other has
made gains but still underway
Developed data mining and SU selection
process
Selected 5 more cases (at 3 outpatient
centers) for this academic year
Working on assessment procedures, team
coordination processes and outcome
measures
Case Report: Meet SD
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SD is a 64 yo male who has
lived in the Delaware County
community for years.
He is a retired electrician and
lives with his wife.
Wife works part time 3 days a
week.
In 2010 -2011 - 13 Admissions
for CHF.
Past Medical History
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BPH
CAD
CHF (7-2010 EF = 30-35 % )
CKDIII
CVA
Depression/Anxiety/Insomnia
Diabetes Mellitus II
Gout
Hypercholesterolemia
HTN
Hypothyroidism
Past Surgical History
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CABG 1998
ICD placement x2 (11/2008 &
dual chamber 3/2010)
L4-L5 Laminectomy
Mastoidectomy
Date
2/1/10
2/9/10
2/15/10
2/18/10
3/8/10
3/26/10
4/7/10
4/25/10
7/4/10
7/6/10
7/11/10
7/24/10
7/27/10
8/18/10
10/14/10
10/22/10
11/13/10
11/22/10
1/22/11
2/23/11
Adm/ER visit
Adm
ER
ER
ER
ER
Adm- ICU
Adm
Adm
ER
Adm
Adm
Adm
Adm
Adm
Adm
Adm
ER
Adm
ER
Adm
Reason
PNA/CHF
Anxiety
Anxiety
Insomnia
Ear pain
CHF
CHF/PNA
CHF
Back pain
CHF/PNA
CHF
CHF
CHF
CHF
CHF
CHF
SOB
CHF
Left w/o being seen
CHF
Length of Stay
1 year
Charges = $520,000; Receipts: $90,000;
Inpatient Admissions: 12; ED visits: 7
• IP Admit
• ED Visit
Comprehensive Medication Management
Opportunity Within the
Patient-Centered Medical
Home (PCMH)
Medication Management
6-2011
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Aggrenox one po daily
Aspirin 81 mg po daily
Lopid 600 mg po bid
Lipitor 80 mg po hs
Zetia 10 mg po daily
Lantus sc daily
Lasix 40 mg po bid
KCl 20 mEq po daily
Norvasc 10 mg po daily
Enalapril 20 mg po daily
Sotalol 80 mg take ½ po bid
Coreg 25 mg po bid
Toprol XL 100 mg po daily
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Colchicine po prn gout
attacks
Vit D 50000 units po q other
month
Flomax 0.4 mg po daily
Levothyroxine 50 mcg po
daily
Celexa 20 mg po daily
Ativan 0.5 mg po hs
Melatonin 3 mg po hs
Diphenhydramine 25 mg
caps
Omeprazole 40 mg po daily
Identify, Resolve and Prevent Drug Therapy Problems
Indication
Adherence
4 Areas
Effectiveness
Cipolle, R., Strand, L., Morley, P-Pharmaceutical Care Practice-The Clinicians Guide2004-2nd edition-McGaw Hill
Safety
Adherence
Provider
Note
Comments
Jan & June 2010
Cardiologist
“Called Rx. Not on beta blocker. Rxist
doesn’t think pt understands
medications. Instructed to take all meds
in bag to PCP to review.”
“did not bring med list, does not know
what he is taking.”
Inpatient
Progress notes
Frequently noted as non-compliant.
Retrospective Medical Record Chart Review Jan 2012
Adm
Date
ER Med History
Med Admin
Record
Chart Discharge
Note
Patient Discharge
Instr.
Toprol XL ??
Toprol XL 25 mg 0900
Coreg 3.125 mg bid
Coreg 3.125 mg bid
3/26/2010
Toprol XL 50 mg hs
Metoprolol 50 mg bid
50 mg twice daily
transfer to Bryn Mawr
4/7/2010
Toprol XL 50 mg hs
Toprol XL 50 mg 0900
Toprol XL 50 mg hs
Toprol XL 50 mg daily
2/1/2010
8/18/2010
10/14/2010
No recorded
medications
No beta blocker
administered
"dc on home meds"
No Beta Blocker on
Patient discharge
instructions
Coreg 25 mg q12hrs
Coreg 25 mg bid
not noted
Coreg 25 mg bid
11/22/2010
Toprol XL 50 mg daily
and Sotalol 40 mg bid
Coreg 25 mg bid
Coreg 25 mg 2x/day
Sotalol 40 mg bid
(checked to not
continue) Coreg 25 mg
bid
1/22/2011
Sotalol 40 mg bid and
Toprol XL 50 mg daily
N/A
N/A
N/A
Sotalol 40 mg bid and
Coreg 25 mg bid
Sotalol 40 mg bid
and ToprolXL 50 mg
daily
Toprol XL 50 mg daily
and Sotalol 40 mg bid
2/23/2011
None recorded
3/23/2011
Toprol XL 100 mg daily
Retrospective medical record review 2-2012
Toprol XL 100 mg daily
SD’s Medication Management
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Resolve Drug Therapy Problems
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Discontinue Sotalol and Toprol XL
Continue Coreg 25 mg twice daily
Communicate with cardiologist
Communicate with pharmacy
Wife educated about medications
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Assumes responsibility to assure medications set up and taken
correctly by patient.
Post-enrollment
Charges = $11,686 ; Receipts= $0.
Inpatient: 0; ED visits:3
Length of Stay
1 year pre-enrollment
Charges= $520,000;
Receipts= $90,000;
Inpatient:12; ED visits:7
• IP Admit
• ED Visit
Family Perspective
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SD is not aware of the
difference.
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Wife is both proud of her
accomplishment as a
caretaker and grateful that he
is not in the hospital and ER
so much.
Hospital Encounters
Readmissions within 30 days
1/2010 – 1/2011
SMS Dsch Date
SMS Entity
2/2/10 DCMH
3/29/10 DCMH
4/10/10 DCMH
4/26/10 DCMH
7/9/10 DCMH
7/12/10 DCMH
7/24/10 DCMH
7/29/10 DCMH
8/18/10 DCMH
10/17/10 DCMH
10/23/10 DCMH
11/24/10 DCMH
TOTAL Admissions in 2010
TOTAL Readmissions
within 30 days
12
6
Sum of SMS Total
Charges
Sum of SMS Total Payments
25558
49112
56778.6
29808
49979
24094
21744
25032
17756.8
43201
21691
37534
9298
2322
9292
9298
6227
4014
5800
7843
2900
7840
10743
7843
402,287
83,460
Now and Future
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Prepared Office Visits
Team approach
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SD and his wife
Physician seeing SD
RN reviews diabetes
Pharmacist med review
Case of CB: “Why is she here so much?”
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CB seemed to be in office waiting room every
week—well dressed, friendly, no apparent
distress
We reviewed the chart—multiple ER visits and
brain CTs over past 2 years
Who is she?
Meet CB
Meet CB
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60yo AAF
Youngest of 5 children; identical twin
Grew up in Philadelphia home with marital discord,
high levels of family conflict
Physically abusive first marriage; strong second
marriage for past 24 years
Has 3 adult children, many grandchildren
On Social Security disability for chronic pain
Works part-time as a hospital chaplain
Currently working on second MA in theology
Family History
Mother - died at 53 y/o from DM complications
Father - died at 62 y/o from CAD, h/o stomach
cancer with mets
Twin sister – BRCA gene positive
2 brothers - one died from suicide, other
brother died from drug and etoh abuse
PMH
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Anxiety/depression
Fibromyalgia
HTN
CVA-1995
TIA
Nephrolithiasis- 2009
PUD, GERD
Diverticulosis
MVA -2011
PSH
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Hysterectomy, oopherectomy ('89)
Bilateral Mastectomy with breast
reconstruction ('00) - precancerous lesion in
nodes and twin sister with BRCA
Cholecystectomy
CB as a Super-Utilizer
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5/5/2009: patient first presents to CFH for primary
care
Patient with multiple ER visits prior to presentation
to CFH for care for various complaints
Patient first identified as a super-utilizer on 8/22/11
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Around this time patient was in ER/admitted multiple times
for syncope/gait imbalance and was complaining of
memory issues, often forgetting her CFH appointments
CB as a Super-Utilizer
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Methods: Electronic medical records from
1996-present reviewed
Date of ER visit, Diagnosis, Disposition recorded
-Radiology files in net-access reviewed for type and
number of CT scans
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How many ER Visits has CB
had since 1996?
Answer- 102 ER visits!
Let’s break it down…
Year
Number of ER visits
1996
2
1997
2
1998
0
1999
0
2000
0
2001
13
2002
6
2003
7
2004
1
2005
1
2007
9
2008
21
2009
21
2010
15
2011
11
2012
4
ER visits broken down by reason…
2009: 21 visits
Date (visits since 5/5/09)
Adm/ER
Reason
5/18/2009
ER
Urticaria
5/19/2009
ER
Urticaria
6/2/2009
Admit
Chest pain
6/5/2009
ER
Nephrolithiasis
6/7/2009
ER
Nephrolithiasis
8/3/2009
Admit
r/o CVA
8/16/2009
ER
Arm strain
8/19/2009
ER
Arm pain
10/11/2009
ER
Head injury
10/12/2009
ER
Headache
10/20/2009
ER
Abscess forehead
10/24/2009
ER
Abscess forehead
11/10/2009
ER
Folliculitis
12/8/2009
ER
Fall
12/14/2009
ER
Flank pain
Other
CT head
CT head
ER Visit breakdown: 2010
15 visits
Date
Adm/ER
Reason
1/2/2010
ER
HA/HTN
1/29/2010
ER
Hand contusion
3/2/2010
ER
Flank/abdominal pain
3/6/2010
ER
Angioedema
Allergic to cipro Rx
3/14/2010
ER
AMS/slurred speech
CT head
4/26/2010
ER
Shingles
5/13/2010
ER
Foot contusion
Fall
6/7/2010
ER
Headache, HTN
CT head
6/27/2010
ER
Urinary Retention
6/28/2010
ER
Urinary Retention
7/1/2010
ER
Urinary Retention
7/15/2010
ER
Rash
Admit
Arm pain/elevated CK
CT head -slurred speech, L
weakness
11/22/2010
ER
HTN
CT head
11/24/2010
ER
Head injury
CT head
9/8/2010
Other
Fall
ER Visit Breakdown: 2011
11 visits
Date
Adm/ER
Reason
Other
1/18/2011
ER
Hematuria
Left before visit completed
1/31/2011
ER
Knee contusion
Dilaudid, Rx vicodin
3/23/2011
ER
Headache
CT head
4/27/2011
ER
Lumbar/cervical strain
5/2/2011
ER
Cervical strain
7/19/2011
ER
Syncope
8/19/2011
ER
Angioedema
8/21/2011
Admit
Angioedema/?CVA
CT head
8/28/2011
ER
Head injury
CT head
8/29/2011
ER
Contusion shoulder
Dilaudid
10/18/2011
ER
Angioedema
Allergic reaction to grape
CT head
ER visits 2012
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2/8/12- admit 24 hour observation for chest pain and
palpitations
3/10/12—lower leg contusion
4/28/12—cough
7/10/12—post-traumatic headache; had head CT
How many CT scans has CB
had since 1996?
Answer- 113 CT scans!
CT scans since 1996
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72 CT head scans
31 CT abdomen/pelvis
3 CT chest
2 CT cervical spine
2 CT coronal/sagital/oblique
1 CT soft tissue of neck
1 CT thorax
1 CT lumbar spine
The Makings of a Super-Utilizer
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Personal and family histories of serious medical
problems
Patient unable to distinguish routine from lifethreatening medical problems
Husband: encourages ER use to decrease pt’s
anxiety; he has own neurological issues
Patient tends to strongly suppress negative
emotions and then experience distress somatically
Lack of PCP continuity
Lack of Continuity of Care
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1st office visit May 5th 2009
18 office visits at CFH in 2009
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16 office visits at CFH in 2010
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Saw 11 different providers in 2009
Saw one provider 6 times (Borgia)
Saw 11 different providers
Saw one provider 3 times (Yun)
18 office visits at CFH in 2011
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Saw 11 different providers
Saw one provider 4 times (previous PCP Colterelli)
Interventions
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Psychotherapy: first session with Barry
Jacobs, Psy.D. on 5/11/2011
Ensure consistent primary physician: Laura
Finocchio MD, current PCP, has first office
visit with patient on 7/28/2011, becomes PCP
8/22/2011
Neuropsychology Evaluation with Andrew J.
Borson, PhD on 10/31/2011
Psychiatric referral 8/12
Neuropsychology Evaluation Results
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Difficulties with short-term visual and verbal memory
and poor processing speed
Executive function intact, good verbal abilities
Poor listening skills
No Cortical or Subcortical dementia
Dissociative or Histrionic-type personality
Memory and organizational issues seem to be
related to psychological issues
Meeting with CB and Husband
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Reviewed neuropsychological results
Told her no evidence of underlying
neurological disease
Said “stress” manifesting itself as somatic
(neurological) symptoms
CB and husband agreed with findings
Agreed to goals of decreasing stress and
decreasing ER visits
Results Since Interventions
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Reduced ER visits and hospitalizations
Regular visits with one PCP
Patient acknowledgment of impact of anxiety,
anger and family stressors on overall sense
of wellness
CB ER visits since Interventions (as of
2/12)
Identified as
Superutilizer
Ja
n
Fe
b
M
ar
A
pr
il
M
ay
Ju
ne
Ju
ly
A
ug
Se
pt
O
ct
N
ov
D
ec
Ja
n
Fe
b
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Lessons Learned and Work Ahead
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We failed patient lack of PCP continuity of
care, took us over 2 years to realize patient
was a super-utilizer; lack of adequate
behavioral health services initially
Our patient CB had many office visits for ER
f/u and “sick” visits, but few preventative care,
f/u general medical issue visits, and
psychotherapy sessions
Closer coordination with ER and Radiology
SU Fellowship
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One year fellowship in which 2 fellows split
time between the Camden Coalition and
Crozer-Keystone outpatient practices
Supported by two-year, $175,000 Aetna
Foundation grant
Goals: become “clinical champion” for the
development of strategies and
implementation of systems to address
frequent utilization
SU Fellowship (cont.)
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Goals (cont.):
Work in multi-disciplinary team
Understand social determinants of healthcare
utilization
Improve care coordination protocols
Analyze data
Apply knowledge gained to CKHS
Keys to SU Operations
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Clinical champions—often based in family
medicine residencies
Motivated health system
Rich electronic data base
Interdisciplinary collaborative team
Engaged primary care network and social
service community
Outcome measures for utilization, costs,
patient and provider satisfaction
Keys to SU Funding
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Seed monies generally coming from health
systems themselves
Brenner has attracted state and national
funders, including CMS and Aetna
Foundation
Difficult to sustain concerted efforts by
collaborative teams without dedicated
funding—despite fact that SU programs are
intended to save money