Students to address “super-utilizers” of health care system

Four ambitious UB health sciences students have been awarded a prestigious, national grant to develop an innovative, local solution to address a key factor in the ever-growing cost of health care: “super-utilizers” of the health care system.

The students received one of 20 “hot spotting mini-grants” awarded to multidisciplinary student teams this summer by the Association of American Medical Colleges (AAMC), Primary Care Progress and the Camden Coalition of Healthcare Providers. The program is run by Jeffrey Brenner of the Camden Coalition of Healthcare Providers, who coined and popularized the concept of hot spotting; he received a MacArthur “genius” grant to address the problem.

The goal of the grant is to encourage student teams across the nation to develop innovative, local solutions to address the problems of a small cohort of “super-utilizers” — more commonly referred to as “frequent fliers” — who utilize the system inappropriately in high-cost emergency/hospital settings. 

“A look at health care cost distribution reveals that a small fraction of the total population accounts for a disproportionately large share of total cost,” explains Jordan Katz, a fourth-year student in the School of Medicine and Biomedical Sciences and leader of the student team. “In 2012, 5 percent of the population accounted for half of all health care expenditures, according to U.S. government figures. Often, visits to the emergency room and subsequent hospitalizations could have been avoided but social and economic issues prevented these patients from receiving timely and cost-effective care. At great expense to the system, these patients are cared for regularly in the hospital setting but their condition remains unchanged and the cycle repeats.”

“Hot spotting” refers to the practice of identifying these patients and developing interventions to better address their needs and more effectively provide care.

When Katz started clinical rotations last year as a third-year medical student, he quickly came to appreciate what Brenner had described.

“Hospital medicine is ill-equipped to meet the unique needs of these patients,” Katz wrote in the grant application. “As doctors, we are trained to implement the most direct and generalizable interventions which can render our care as somewhat generic and less than holistic. Success is dependent on inherent trust in medical providers, low complexity and relatively few adverse social determinants of health. For the super-utilizer, the current approach has failed. Despite having a seemingly constant presence in the hospital, these patients are chronically misunderstood.”

Katz and his UB colleagues hope to arrive at a better understanding of the challenges faced by a few of these patients by partnering with the Jericho Road Community Health Center in Buffalo, a federally qualified patient-centered medical home. Eighty percent of its patients are on Medicaid or are uninsured and have incomes at or below 200 percent of the federal poverty level.

“As an organization,” Katz says, “Jericho Road has already adapted a model inspired by Dr. Brenner to provide improved care for the most complex and vulnerable patients in their practice.”

Using electronic medical-record data, including continuum-of-care records that reflect a patient’s utilization footprint, Katz and his colleagues will identify four Jericho Road patients who qualify as super-utilizers.

Once appropriate patients have been identified and agree to participate, the team will work closely with them to identify obstacles, establish goals of care and develop sustainable, cost-effective solutions. Grant funding is available to implement student-proposed measures. With guidance from the Camden Coalition, faculty advisers and support from Jericho Road providers, the student team will generate and execute an individualized care plan. The project ends Jan. 1, 2016.

The UB students have substantial multidisciplinary experience in working on social justice and community service. In his previous work with Jericho Road and through the UB medical school’s chapter of Physicians for Human Rights, Katz has advocated for vulnerable populations. He is committed to primary care and is a Primary Career Track award winner and Primary Care Research Scholarship recipient at UB.

In addition to Katz, the other students are Mallory Abdula, a registered nurse and candidate for a Doctorate of Nursing Practice from the School of Nursing, who is focused on quality improvement emphasizing outcomes and efficiency; Elizabeth Borngraber, a candidate for a master’s degree from the School of Social Work, focusing on women’s health, health access and policy; David Essi, a PharmD candidate in the School of Pharmacy and Pharmaceutical Sciences who has an MA in bioethics and attended an Epidemiology and Population Health Summer Institute at Columbia University.

“This is an energized and talented group of students who will be working together over the coming months to make a difference in the lives of a group of patients who have fallen through the cracks,” says Ranjit Singh, associate professor in the Department of Family Medicine and a faculty adviser on the project. “They will be modeling interprofessional teamwork that rejects the current fragmented approaches and embraces the patient as a complex human being with dynamic challenges (such as transportation, housing, food security and other social needs) and helps to overcome these challenges.”

Other advisers on the project are Charles Syms, clinical associate professor in the School of Social Work, who has extensive experience in addressing such issues as domestic violence, forensic mental health and substance use disorders, and Eleanor Nixon, a family nurse practitioner at Jericho Road, who specializes in managing high-risk patients requiring intensive needs assessment and comprehensive care coordination.