Published On: January 2017 in Kaiser Health News. Read the story here. This KHN story also ran on PBS NewsHour.
HOUSTON — Donning a protective gown, rubber gloves and a face mask, Dayna Gurley looks like she's heading into surgery. But Gurley is a medical social worker charged with figuring out why her client, a man who uses more health care services than almost anyone else in Houston, has been in three different hospitals in the last month.
The patient, who asked not to be identified, has chronic massive ulcers, AIDS and auditory hallucinations. He rents a cot in another person's home but is more often homeless, with no family to help him.
"It's almost like self-sabotage," Gurley said about her many attempts to steady her client's life. "We get really close to an important doctor's appointment or getting him connected with stable housing, and his impulsiveness gets in the way of that."
Patients like the Houston man are health care's so-called "super-utilizers"— people with complex problems who frequent emergency rooms for ailments more aptly handled by primary care doctors and social workers. They cost public and private insurers dearly — making up just five percent of the U.S. population, but accounting for 50 percent of health care spending.
As health care costs continue to rise, hospitals and doctors are trying to figure out how to find these patients and get to the root of their problems.
An effort to do just that started in New Jersey's poorest city, Camden, more than a decade ago. Inspired by the way police departments mapped crime data to detect "hot spots," family physician Dr. Jeffrey Brenner dug into ambulance records and emergency department data to show how high-cost patients were shuttling between city hospitals.
"In America, we're medicalizing social problems and we're criminalizing social problems, and we're wasting huge amounts of public resources," Brenner said. "We have the wrong tools to solve the wrong problem."
To steer patients away from expensive emergency care and push health systems to change the way they do business, the Affordable Care Act funds programs called Accountable Care Organizations. These are networks of hospitals, physicians and others who team up to improve care, lower costs and reap the savings.
Brenner's team at the Camden Coalition includes Latonya Oliver and Bill Nice, social workers who seek out patients like Peter Bowser in local neighborhoods. Bowser was once homeless and went to the emergency department nearly 30 times in one year.
But after Oliver and Nice helped get a permanent roof over his head, Bowser's trips to the ER all but stopped.
"I think you'd prefer to spend your time here than in the hospital any day of the week," Nice said to Bowser on a recent afternoon, gathered at the kitchen table in his tidy apartment.
This high touch, data-driven approach has yielded big savings. ER visits for the first group of patients dropped by 40 percent, cutting monthly hospital bills from $1.2 million dollars to $500,000.
Since then, Brenner has sought to spread the model around the country. One example is the Patient Care Intervention Center in Houston, a sprawling city desperate to aid its sickest and most isolated patients.
While the more than 100 hospitals here typically know their own super-utilizers, they had no way of knowing the top users across the entire city.
