Several years ago, R. Corey Waller, M.D., an emergency department physician at Spectrum Health, a seven-hospital system based in Grand Rapids, Mich., began noticing a small group of patients who were recurring visitors to his ED. Waller, who generally spends three to five minutes with each patient who ends up in the ED, gradually became convinced that wasn't enough time to meaningfully assess problems and provide appropriate care for high-frequency patients.

"If it's somebody you've seen a lot, you can't have these conversations in a couple of minutes," Waller says.

In 2008, Waller decided to quantify what he had noticed anecdotally. He discovered that 950 patients had visited the ED at two of Spectrum's hospitals more than 10 times apiece in the previous year. All told, those visits amounted to a staggering 20,000 hospital visits and an estimated $40 million to $50 million in treatment costs.

Waller and Spectrum Health aren't alone. According to a report released earlier this year by the Agency for Healthcare Research and Quality, 1 percent of patients accounted for roughly a fifth of all health care spending in 2009, or more than $90,000 per person. Five percent of patients accounted for half of overall health care costs. By contrast, 50 percent of patients accounted for only 3 percent of health care spending, the AHRQ report found.

The spending linked to high utilizers can't be chalked up simply to uninsured patients without access to primary care. According to a recent report from the IMS Institute for Healthcare Informatics, 1 percent of patients in a survey of 10.6 million health plan members accounted for 25 percent of their plan's total costs, and 5 percent accounted for slightly more than half, mirroring the AHRQ survey.

"There's a small segment that is burning through 20 percent of our society's wealth at a massive rate," says Doug Eby, M.D., vice president of medical services for the Southcentral Foundation health care system in Anchorage, Alaska, which, like Spectrum Health, has a program in place to identify high-utilizing patients and coordinate better care for them.

Waller didn't get discouraged by his investigation; starting in 2008, he set aside a half-hour each Wednesday to meet with 30 of Spectrum's highest-utilizing patients in a group setting in the back of an urgent care center. In the first six months, only one of the patients missed an appointment, and Waller soon discovered that most had a litany of undiagnosed problems that had gone undetected during their repeated encounters with the health care system.

Over time, the sessions helped reduce ED visits in the targeted group by 85 percent. In 2011, Waller and Spectrum launched the Center for Integrative Medicine, part of the Spectrum Health Medical Group, with a specific charge to assess and treat high-frequency patients throughout their system.

"As we develop data, we continue to find [that] these patients are generally misunderstood and have a large amount of social issues," Waller says.

Looking anxiously ahead to January, when the incoming president and Congress are expected to confront a growing federal deficit, in part by mandating major reductions to health care spending, providers are pursuing interventions that address the patients who generate the lion's share of their costs. Efforts are geographically disparate — from the Native Alaskan communities served by the Southcentral Foundation, rural populations in Northern Colorado and impoverished urban communities in Camden, N.J., and the West Side of Chicago. However, they take a similar path: Identify high-frequency patients, develop detailed care plans and rely on case managers to build trusting relationships that, providers hope, will encourage healthier habits, better medication adherence and other behaviors to better manage their conditions and keep them out of emergency departments and hospital beds.

"People with complicated needs live complicated lives," says Carol Beasley, director of strategic projects at the Institute for Healthcare Improvement. "Our systems are not necessarily great at meeting those needs."

The patient profile

By identifying the socioeconomic characteristics of high utilizers, many providers hope to reach out to vulnerable populations before they need emergency medical treatment. Mark Wallace, M.D., president of the 10-year-old North Colorado Health Alliance, works with community groups and local social service agencies to identify individuals with chronic conditions, many of whom struggle with related social issues that include insufficient access to food or housing difficulties.

"We want to engage at that earliest level," Wallace says.

Primary care clinics are another key location for identifying high utilizers. Last year, officials at CareOregon, a nonprofit health plan serving Medicare and Medicaid patients, began "geomapping" patients with high health care costs to see where they were receiving primary care. As it happens, two local clinics were serving 200 of the high-utilizing patients, giving CareOregon a chance to identify key commonalities among those patients.

"The population had a lot of social disorganization, life chaos, instability in housing and social support, and either a mental health or substance abuse [problem] actively impacting them," says Rebecca Ramsay, R.N., care support manager for CareOregon.

Those insights can help providers develop linkages between patients' chronic conditions and their day-to-day lifestyles and environment. At Mount Sinai Hospital in Chicago, where diabetes and congestive heart failure initiatives seek to reduce readmissions, patients receive regular assessments for substance abuse, which is often a comorbidity associated with congestive heart failure. "There are lots of [social] reasons they end up being hospitalized," says Cara Pacione, director of social services at Mount Sinai Hospital. "Substance abuse is huge with congestive heart failure patients. We do an assessment with every patient."

Hot spotters

Over time, providers who work with high utilizers are able to categorize patients into distinct groups and develop appropriate care plans. Southcentral's Eby says most of the system's high-utilizing patients broadly comprise three groups: patients with chronic mental illness, a "medically fragile" population of primarily elderly patients, and a group Eby describes as "socially disintegrated," who tend not to engage in self-care, have few family resources and display dependent personalities. For patients with significant mental health issues, a behaviorist often becomes the patient's primary care provider; for those with medically complex conditions, a nurse fills that role.

The strategies employed by Southcentral commonly are known as "hot spotting," which targets specific diagnoses and patient populations with personal interventions that bring together providers and community groups to solve problems. The IHI's Beasley says hot spot strategies can help providers target behavioral patterns that have often flown under the radar of the health care system.

"What we're trying to do is have an impact at the population level," Beasley says. "Where can you have a big impact with a little effort? Where do needs concentrate? Where do costs concentrate? The notion of dealing with hot spot populations comes around out of that."

The Camden experiment

The challenge, Beasley says, lies in scaling the experiments to larger populations. One well-reported hot spot experiment has taken place in Camden, N.J., a city of 77,000 just across the Delaware River from Philadelphia and one of the poorest cities in the United States. (See sidebar page 33.)

Back in 2008, Jeffrey Brenner, M.D., executive director of the Camden Coalition for Healthcare Providers, began an exhaustive survey of the city's health care costs that analyzed the total visits by residents of every block to various local hospitals and clinics. Brenner then examined patients' primary diagnoses and the cost of care.

After poring through six years of claims data, Brenner discovered that a single public housing development was responsible for $12 million in health care costs from 2002 to 2008. The team also learned that many Camden "superutilizers" are homeless; others have difficulty accessing transportation or have poor social relationships, while some simply have ineffective primary care networks.

"It was like sending a deep space probe out into the delivery system," Brenner says. "[High utilizers] turn out to be a mirror you can hold up to the health care system."

Today, the coalition's multidisciplinary outreach team works with patients across the city to develop a long-term medical home. The team, which includes a nurse practitioner, a social worker and a medical assistant, meets with patients in settings that include homeless shelters and Camden street corners. The program is supported by a health information exchange, launched in 2010, with the capability to receive near real-time information on patients admitted to the city's three hospitals each day. The coalition then uses that information to help arrange primary care visits and other health care services for admitted patients.

Ultimately, the care coordination insights the program gleaned can be used, with modifications, on any patient population, Brenner says. "We started with a group that no one wanted," he says. "But it turns out that if you're good at caring for homeless schizophrenics ... you're also going to be good at caring for suburban baby boomers."

The power of relationships

Each group needs a different approach, Brenner says. While there are generalities to be extracted from the data, he stresses that providers still have to work at the face-to-face level to truly engage patients and identify potential problems and barriers to better health.

For instance, Brenner related the story of an elderly patient who was having difficulty controlling his diabetes. During a visit to his apartment, the care team watched as the man filled his syringe for his daily insulin shot with air. It turned out the man was also visually impaired and needed assistance with his shot.

Effectively reaching out to patients with complex care needs requires clinicians with a certain type of personality, the Southcentral Foundation's Eby says. The system specifically looks for and trains staff with both the temperament and willingness to work with patients to change their health choices and present options for better choices. "In the long term, [health care] is about developing trusting, accountable, messy human relationships," he says.

Ultimately, Eby says providers need to realize that while quality improvement methodologies are important, the truly significant opportunities for both improving outcomes and reducing costs will be found by improving the behavior of the patients who consume the most resources.

"Health care thinks of itself as a manufacturing industry," Eby says. "[Health care] has fallen in love with Six Sigma and Lean and people think ... if you get the right pills and procedures, somehow health is going to break out. We fundamentally disagree with that."

Next month: An in-depth look at the strategies hospitals and communities are using to treat and communicate with high utilizers of health care.


Closing the revolving door

As pressure to reduce readmissions builds, many hospitals are developing intensive, relationship-based treatment regimens that rely on strong communication between patients and care managers to stop patients from joining the ranks of high utilizers after an initial hospitalization.

Earlier this year, Willie Barnes, 65, was admitted to Mount Sinai Hospital in Chicago after showing up at the emergency department with shortness of breath. Barnes, who had had triple bypass surgery 10 years ago, was ultimately enrolled in Sinai's congestive heart failure program, which is designed to avoid readmissions.

Every week or so, Barnes gets a call from a disease manager at Mount Sinai, who checks in with him on both his diet and medication adherence. In that time, the disease managers have helped Barnes fill a prescription he was having difficulty getting from a local drugstore, and have helped him shed a two-liter-a-day soda habit.

Two months later, Barnes says he's lost 30 pounds and is no longer suffering from shortness of breath.

Fellow program member Valerie Shavers, who was diagnosed with congestive heart failure last year after an episode in which she lost consciousness while driving her car, has stopped smoking, drinking carbonated soda and eating microwaved food.

Shavers, who is also a cancer survivor, says the disease manager and patient navigators with whom she talks each week at Mount Sinai differ significantly from health care professionals and counselors she's encountered on previous clinical experiences. "They were more like a friend calling," she says. "[We talk about] the weather, or if I'm going out of town."

Since they joined the program, neither Barnes nor Shavers has been readmitted to Mount Sinai, says Roelean Duncan, R.N., a disease manager who works with both patients.


Executive Corner

Find out who your "1 percenters" are

Get started by analyzing patient data to determine which patients are frequent visitors to the emergency department, and why they end up there.

Understand the differences

Different patients become high-utilizers for different reasons. Approaches must be tailored to them.

Make the first move

Many hospitals are reaching out to high-frequency patients and inviting them to join programs designed to combat specific chronic conditions like congestive heart failure or diabetes.

Identify staff who care

Hospitals also are relying on case managers to make regular phone calls to patients to ensure they're managing their conditions and regularly taking their medications. The case managers are expected to build trusting relationships.