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John Wood, MD, FAAFP, Medical Director, Care Connections

Jeffrey Martin, MD, FAAFP, Lead Physician Extensivist, Care Connections

A recent report by the Pennsylvania Healthcare Cost Containment Council (PHC4) focused attention on “super utilizers,” patients who use a disproportionate amount of hospital services. The PHC4 report looked at nearly 22,000 Pennsylvanians who were admitted to their local hospital more than five times in 2016. While these patients account for just 3 percent of all hospital admissions last year, they accounted for 10 percent of hospital costs (about $1.25 billion). Most of that cost was paid for by the taxpayer-funded Medicare and Medicaid programs.
Big numbers, for sure, but the trend is positive. Hospitals and health systems across the commonwealth have developed innovative programs to address the often-complex and multifaceted needs of “super utilizers.” These programs are making a difference. In 2014 more than 24,000 Pennsylvanians fell into this category; last year the number was just under 22,000. Lancaster County is making particularly remarkable progress. In 2012, we ranked sixth in the state for the number of super utilizers per 10,000 residents (12.9); last year we ranked second (11). These programs are beginning to gain traction and should be expanded.
LG Health calls its program to help these chronically ill patients “Care Connections.” Care Connections brings a range of expertise and support to each patient and looks at each patient’s health situation in a holistic manner. Not surprisingly, super utilizers often have multiple and long-term health challenges that can include physical ailments, mental health issues and addictions. Difficult social, family or economic conditions also can contribute to frequent Emergency visits and hospitalizations.
The treatment teams in Care Connections include physicians and nurses, of course, but also physical therapists, pharmacists, behavioral health counselors, social workers, addiction experts and even attorneys. In this fashion, the Care Connections team can develop a comprehensive plan for each patient’s needs.
This approach benefits the broader Lancaster community. Among the 186 patients enrolled in Care Connections since the program’s beginning in late 2013, LG Health has measured a 42 percent drop in Emergency Department visits and a 54 percent drop in the number of admissions to Lancaster General Hospital. Avoiding unnecessary visits relieves Emergency Department crowding, and the declines in utilization also generate significant reductions in costs associated with caring for these patients.
For the patients themselves, Care Connections often represents a chance to regain a sense of hope and control over their health and their lives. Managing diabetes can be difficult under the best of circumstances. Managing diabetes while also struggling with depression, unemployment, lack of transportation and dysfunctional family relationships is often overwhelming. Without the coordination and support offered by Care Connections and similar programs, patients often simply drift from one health crisis to the next.
Take the case of “Jose” (not his real name). Dangerously overweight and depressed, and struggling from a host of related pulmonary and circulatory diseases, Jose frequently arrived at the hospital Emergency Department in crisis. After enrolling in Care Connections, our team was able to coordinate a range of interventions that helped Jose get counseling, address his medication needs and lose weight. His overall health improved, and today Jose volunteers in LG Health’s physical therapy department and with the Care Connections program, supporting other enrollees.
 “Sylvia” (not her real name) is a middle-aged woman suffering from kidney disease, hypertension and diabetes. Sylvia enrolled in Care Connections after a series of frequent Emergency visits to the hospital. The care team discovered that Sylvia also suffered from an underlying chemical addiction and an abusive relationship in her home. Interventions for these issues put Sylvia on a path to recovery and virtually eliminated related Emergency visits to the hospital.
Programs such as Care Connections are examples of innovation in how health care is delivered, and they address the need for hospitals and health systems to think about supporting the overall health of the community and not just focusing on acute episodes of care. Lancaster County can take pride that we are making progress in what has been a long-term problem. As our nation debates the elements of health-care reform, Care Connections and other holistic approaches to health should be embraced and expanded.

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