Super-utilizers get red carpet treatment

Abstract

MetroHealth Medical Center in Cleveland has partnered with two health plans to provide intensive care coordination for high-cost patients with multiple medical problems and, often, behavioral health issues. Nurse practitioners at two primary care sites provide one-on-one care coordination for super-utilizers. They assess the patients' needs, help coordinate community resources, and prepare a treatment plan that is flagged when patients visit the emergency department. The nurse practitioners meet with health plan representatives monthly and brainstorm on ways to meet patients' needs.