A small number of individuals drive much of the cost in the American health care system. They have multiple comorbidities; complex, hard-to-manage needs; and chronic conditions. These patients are known as "superutilizers" because they have frequent contact with the medical system. Over time, their chronic conditions worsen, leading to ever more expensive, invasive and risky treatment.

Transitional care model

Kalispell Regional Healthcare, based in Kalispell, Mont., has teamed with the Mountain-Pacific Quality Health Improvement Organization to introduce a modified transitional care model, which is intended to provide comprehensive in-hospital planning and home follow-up for chronically ill, high-risk older adults hospitalized for common medical and surgical conditions. The goals are to (1) improve the health and well-being of patients frequenting the health care system by identifying high-cost, high utilizers, and (2) reduce unnecessary use of health care resources by improving care coordination and communication across community assets, including health care, housing, transportation, meals and safety-net resources. In addition, the model will test tablet technology as as a way for rural patients living in frontier regions to communicate with health care providers.


Kalispell Regional Healthcare is 343-bed health care system serving more than 190,000 people within a geographical region of 20,000 square miles and employing more than 4,000 team members. The health care system comprises two acute-care hospitals — Kalispell Regional Medical Center and North Valley Hospital — and a mental health and substance abuse facility. Core services include cancer care, cardiovascular care, neuroscience and spine care, trauma Level III emergency services, neonatal intensive care and orthopedics. In addition, the system includes six primary care clinics certified by the National Committee for Quality Assurance for their Patient-Centered Medical Home programs.

KRMC is a regional referral center offering a full spectrum of health care services provided by a medical staff of more than 400 physicians, physician assistants and nurse practitioners, and 3,400 employees throughout 100 departments. Nearly 70 physician specialists see patients at outreach clinics.

NVH is a 25-bed critical access hospital based in Whitefish, Mont., and is a public benefit nonprofit corporation. Core services include 24/7 emergency, a birth center, orthopedics and minimally invasive surgery. NVH operates primary and specialty care clinics in Whitefish, Columbia Falls, Kalispell and Eureka, Mont., in addition to a structured outpatient mental health service in Whitefish.

In 2014, Mountain-Pacific Quality Health applied for and received nearly $2 million in funding for a Special Innovations Project from the Centers for Medicare & Medicaid Services to apply transitional care philosophies in Montana, bringing together new and existing resources and technologies to develop intervention teams — called ReSource Teams — and support superutilizer patients. The award was combined with a $250,000 grant from the Robert Wood Johnson Foundation, and the project is being demonstrated across Montana.

ReSource teams

ReSource teams are multidisciplinary groups of trained professionals that include a primary care physician, pharmacist, ReSource nurse, behavioral health professional and community health worker linked to a variety of community resources. ReSource teams are adapted to each community. Unlike a traditional transitional care model, which adds resources to a dense geographic area, ReSourcing would bring together new and existing community resources and technologies to develop an intervention team covering a broader geographic range. In this instance, the team is linked to Project ECHO (Extension of Community Healthcare Outcomes), a model aimed at increasing access to specialty expertise, knowledge and support in underserved areas.

In this community-based approach, the ReSource nurse acts as a care coordinator for the patient and does medical assessments, caregiver burden assessment, patient safety assessment, patient and caregiver education and medication reconciliation. The ReSource nurse also coordinates with the physician and helps to establish the patient’s medical home. Community health workers augment the nonmedical care and break down barriers to care, including many social determinants of health, such as lack of transportation, secure housing and food. In addition, a behavioral health consultant helps the team develop strategies to work with patients who have coinciding mental health needs. Teams teach patients self-reliance and move them toward primary care management under the motto, “I do, we do.”

How it works

This approach focuses on patients who are completing a hospital stay or who have had repeated utilization within six months, such as:

  • Two or more inpatient admissions.
  • Two or more observation stays.
  • Three or more emergency department visits.

ReSource teams help patients who:

  • Can benefit from more coordinated primary care.
  • Have medical problems that can be prevented, such as diabetes.
  • Are not near the end of life.
  • Do not have conditions that will continually get worse.
  • Have documented or undocumented mental health issues correlating to superutilization.

A nurse visits the patient prior to discharge from the hospital to determine the need and appropriateness for participation in the program. If the individual is enrolled in the program, the ReSource nurse will visit within the first week of discharge to home and gather clinical information. That information can then be shared with the community health worker who will focus on the social determinants of health. Tablet computers are used to facilitate communication between patients at home and members of the ReSource team in the hospital, an important tool for implementing or modifying a plan of care for socially and medically complex patients living in rural Montana.

The community health worker and ReSource nurse will make additional visits and, after 30 days, assess symptoms, review care plan compliance and evaluate progress on socialization. That information will be shared with the ReSource team. The patient may then graduate, extend enrollment or be referred to his or her medical home. If enrollment is extended, the community health worker and ReSource nurse will continue visiting up to 90 days, at which time the team will review the patient’s chronic disease self-management skills, health care navigation skills and compliance with the care plan. The ReSource nurse and community health worker then summarize the information for the patient’s primary care physician in a coordinated plan of care.

The care continuum

The program also offers care coordination software that allows entities to share patient information. With the software, primary care physicians can see that their patients are enrolled in various community resources, such as transportation shuttles or Meals on Wheels, and prevent duplicating efforts. The software also allows the team to track whether the patient avoids medical crises after progressing from the outpatient care program.

Essential to the success of the effort is the ability of the ReSource nurse to serve not only as a medical mediator but also to coordinate activities across the breadth of community resources. This involves recognizing that the challenge is more than just filling medical gaps; rather, it is observing the whole picture of a person’s life and identifying unmet basic needs. By building trusting relationships with patients, the ReSource team is better able to achieve improved compliance and more favorable outcomes.

Rural teams often work in isolation. Monthly case conferences with experts and peers addressing de-identified complex cases are essential for learning and knowledge transfer and achieving the desired outcomes.

To meet the goal of clearly seeing and effectively responding to the whole picture, a diverse range of community organizations — including Western Montana Mental Health, Pathways Treatment Center, Summit Medical Fitness Center, ASSIST, Flathead Community Health Center, the Brendan House skilled nursing facility and others — convened in 2012 and formed the Northwest Montana Care Transitions Coalition. It has become an integral part of the special innovation project and provides partners with a way to collect data that documents whether or not the effort is working. It also allows the coalition to extend its reach.


Kalispell Regional Healthcare will track admissions/readmissions, ED visits, in-person and video chat visits, and patient satisfaction. By the conclusion of its second year, this special innovation project is forecast to reach 65 patients and reduce inappropriate visits to the ED by one per patient for savings of approximately $83,400. That would translate to almost $1 million in savings to Medicare, Medicaid and the Indian Health Service through reduced readmissions.


Every patient is different, as is his or her motivation for utilizing health care. Likewise, every provider is different, and it is imperative that all providers communicate with one another to meet the needs of their patients and reduce unnecessary use of health care resources. Population health will improve by enhancing care coordination and communication across community organizations, including health care, housing, transportation, meals and safety-net resources.

Engaging patients to commit to and participate actively in their health care is critical to success and requires a supportive environment led by an empathetic leader. The need for motivational interviewing, trauma-informed care and substance use awareness are important characteristics for the ReSource nurse. A ReSource team that can function across multiple levels of care and social determinants will be in the best position to achieve the program's goals.

ReSource teams offer an approach to improving the health and well-being of patients who frequent the health care system, conserving scarce resources by identifying high-cost high utilizers and coordinating their care. Ultimately, this approach will improve the experience of care for both caregivers and recipients as outcomes improve and efficiency is achieved.

For more information on Kalispell Regional's transitional care model, please contact Mandi M. Cole, BSN, RN, ACM, director of case management, Kalispell Regional Medical Center (mcole@krmc.org).

John Supplitt is senior director, American Hospital Association Constituency Sections.