Tech Helps Reach High Utilizers to Lower ER Costs

Alaska's Mat-Su Health Foundation project provides a model that its proponents say can be replicated anywhere.

Healthcare continues to be bedeviled by "frequent flyers"—high utilizers of expensive emergency departments. But one healthcare system in Alaska is showing how, with the right dose of technology, and focusing on social determinants of health, these high utilizers can be better served, and dramatically reduce ER costs in the process.

To better understand the strategy, it helps to take a look at the organizations involved and the timeline. 

Community Needs Assessment Reveals Dire Needs

Mat-Su Health Foundation, co-owns the Mat-Su Regional Medical Center, which serves a population of 100,000 in an area defined as the Matanuska-Susitna Borough, or Mat-Su for short. (Alaska uses borough designations instead of counties.) Located in Palmer, Alaska, the hospital is situated in one of the fastest-growing population areas in south central Alaska.

In 2013 the Foundation conducted a community health needs assessment, which found mental health, emotional health, and substance use disorder as the highest priority health issues facing the region. In addition, the population had twice the national average yearly suicide rate.

To address these challenges, the Foundation convened a task force, which included state and local leaders, as well as first responders, to research and then tackle the problem at all points where patients in crisis touched the system.

A follow-up study demonstrated additional concerns across all payers and all age groups, says Elizabeth Ripley, chief executive officer of Mat-Su Health Foundation. About 99 patients had five or more visits to the emergency department; 66 had 10 or more visits, and 19 people had a total of 477 visits. To reduce these super-utilizers, Ripley convened leadership, including Anne Zink, MD, then head of the hospital's emergency department, and now chief medical officer for the state of Alaska.

Elizabeth Ripley, chief executive officer, Mat-Su Health Foundation (Photo courtesy of Elizabeth Ripley)

Additional data for 2013 painted a grim picture:

• The emergency department saw 2,391 behavioral health patients for a total of 6,053 visits, costing an estimated $23 million.
   
• These patients had higher charges, more frequent visits, and were more likely to return to the hospital within 30 days, as compared to other patients.
   
• An additional $1.6 million was spent on law enforcement, 911 dispatch, and transportation.  
   
• Alaska state troopers responded to 851 health-related emergency calls, and EMS/ambulance services responded to an average of 432 calls.

Broadening Community Involvement

"Besides doing all the data crunching, we interviewed a lot of people for the reports," Ripley says. "We interviewed the chiefs of police from two towns, and the captain of the Palmer detachment of the state troopers."

Those interviewed, naturally, showed heightened interest in reading the report. The state trooper captain, went further, taking a 40-hour class on how to incorporate crisis intervention training and mental health first aid practices into law enforcement. "He came in and said, 'I've had a bunch of wins,' " Ripley says. He wanted all first responders in the Mat-Su Borough to be similarly trained. Today every officer at the Alaska State Trooper Academy in Sitka receives mental health first aid education, and 25 Mat-Su troopers have completed crisis intervention training.

Yet that was just the beginning of the transformation that became the High-Utilizer Mat-Su, or HUMS, program. In late 2016 and early 2017, a team from Mat-Su Borough traveled to meet King County to meet Enrique Enguidanos, MD, MBA, and see firsthand the kind of crisis intervention that he and his company had come up with there, to good results.

Enguidanos had been the medical director for Providence Regional Medical Center Everett, which had the largest emergency room in the state of Washington, an ER that saw 120,000 people a year. "We had a problem with utilizers, and my nursing director and I just created a grassroots program out of our hospital, and it had tremendous results."

The key: Knowing when a high utilizer was presenting at the emergency room, and getting a mental health counselor to show up in person, while the patient was still at the ER, and get them into the mental health system right then and there, during the crisis.

ADT Technology Bolsters Efforts

To do that, Enguidanos relied on one of a new generation of tools mining admission-discharge-transfer (ADT) events, collected by every hospital. This equipped the mental health intervention team with information to know, at any hour of the day, when and where the high-utilizer patient was presenting.

The tool he used, the Collective Platform (formally known as the Emergency Department Information Exchange, or EDIE), provided by Collective Medical, enabled his intervention team in Washington state to reduce emergency department visits by 80%, by instead connecting frequent flyer patients with primary care physicians and federally qualified health centers.

Programs such as Collective Medical's embody the first of seven best practices developed by the Washington State Hospital Association of redirecting care to the most appropriate setting. For example, it involves exchanging patient information among ERs, helping patients understand and use appropriate sources of care, instituting case management to reduce inappropriate ER utilization, and implementing guidelines to discourage narcotic-seeking behavior.

In 2017, due in part to Zink's advocacy, Alaska implemented the Collective Platform statewide, which paved the way for Enguidanos' implementation of the program in the Mat-Su service region. To extend his expertise, Enguidanos founded and became chief executive officer of Community Based Coordination Solutions (CBCS), a healthcare services consultancy which contracted with Mat-Su Health Foundation to implement its HUMS program in that Alaska borough. "Typically, what I do is contract with payers around the country, I'll bring in my own staff, and we go at risk," Enguidanos says. "It's really about finding the homeless, mental health, and substance abuse patients that others can't engage."

One way that CBCS initially finds these patients, about 25% to 30% of the time, is when CBCS staff gets a text that one of these patients has shown up in an emergency department. "No one has ever been able to see them," Enguidanos says. "Payers all have them on their rolls. They've been assigned to a case manager, but the case manager has never met them, because the patients don't answer their phones." Some frequent-flyer patients, in fact, had five or six care coordinators who had never communicated with each other.

Having already created relationships with the emergency department, CBCS staff proceeded to ask ER staff if the patient is okay meeting with CBCS staff at the ER. If the patient agrees, CBCS staff then meet and ask each patient about their particular care gaps or concerns.

"Probably half of those visits come after hours, when traditional care coordination programs aren't going to be around," Enguidanos says. Even if the patient's concern is just about how to get transportation to an appointment the following morning, these after-hours care coordinators help however they can.

Throughout the Alaska rollout in the Mat-Su area, Zink spearheaded this effort, Ripley says. "I just can't understate how important it is to have a champion," she says. "She's a super-communicator, and in a case like this, there were so many people we had to convince along the way—legislators, administrators, ER docs."

"A huge piece of the work is putting the patient at the center," Ripley says. "That's how we got people to the multidisciplinary team table."

Program Results in Significant Savings, Yet More Work is Necessary

In 2018, the first year of the program, the medical center reduced emergency department utilization by more than 52%, saving $1.9 million, which includes the cost of HUMS. For those patients with a decrease in utilization, the system saved $2.167 million. "And we've reduced the cost of the program over time," Ripley says.

The upfront investment is real, and Mat-Su could afford to do that by plowing nonprofit proceeds back into programs like HUMS. At present, that limits the size of the program to 100 patients. "But the payoff for individuals, families, and the community is just extraordinary," Ripley says. Many stories already exist of individual patients for whom HUMS has turned their lives around, leading to better health, employment, and more, she adds.

It also makes concrete the care plans previously created by care coordinators for these patients, Enguidanos says.

"Suddenly, we had one plan that was working," he says. "It was how much we could do with just community workers and making that initial engagement. After about a year, we can get patients in a less acute program. We can reach them by phone. It's not that they didn't have phones before. It's just that they didn't see any value in engaging with us."

The patient quickly becomes invested in their own care, which makes the efforts of clinicians all that much easier, Enguidanos says.

CBCS' contract with Mat-Su Health Foundation concluded after a two-year run, but HUMS continues, operated by LINKS, a nonprofit agency that the Foundation funds. Despite its success, HUMS essentially represents a proof of concept that still needs to be scaled. For that to happen, other stakeholders— namely, payers and states—need to go all in, including funding and operation. Ripley says.

"We shouldn't even have to prove the model anymore," she says. "We should just be deploying it across the country. It's ridiculous that we're not.

"Our next level is getting the payers engaged," Ripley says. "They would have a lot more leverage. Now it's all voluntary [patients must opt in]. But with a little leverage, we could bring quality of life to a lot more people.

"At this point," she continues, "where America has the most costly healthcare system in the world, why can't we pivot to make sure all of our hospitals and communities have a program like this?"

Part of the answer may lie in the fact that the steps taken by Mat-Su Health Foundation have only begun to solve the problem. Ripley admits that the number of super-utilizers of the emergency room has, in fact, continued to grow each year, despite the cost savings that HUMS has unlocked.

"We need other measures to stem the tide," Ripley says.

[Editor's note: This story was updated on 4/17/21 to reflect that Mat-Su Health Foundation co-owns the Mat-Su Regional Medical Center, and due to a previous editing error, the article now correctly indicates that 19 people had 477 emergency room visits prior to launching the solution.]