Perspectives on Root Causes of High Utilization that Extend Beyond the Patient

In 2012, Mercy Health Saint Mary’s embarked on a journey to intervene on high-need, high-cost (HNHC) patients. Rather than following traditional approaches of hiring new care managers or creating new clinics, we focused on how we could change the system’s response to complex patients. One of the key outcomes from this approach was implemented by a master’s prepared clinical nurse leader, who developed a Complex Care Resource Center and coled an interprofessional complex care committee with an emergency department (ED) medical director to create a tool embedded in the electronic medical record (EMR) called Complex Care Maps (L. Hardin et al, unpublished data, 2016). The Center receives referrals from any provider who identifies a patient with high-frequency health care system access or complex unresolved needs. Intervention includes analysis of root cause drivers for patient instability, coordination with cross-continuum providers to develop a plan of care, and entry of the plan into a succinct Complex Care Map that equips providers in the moment of encounter with helpful information to improve outcomes. After serving more than 1400 patients through the Center and developing more than 800 Complex Care Maps, we have had the opportunity to observe key themes driving high utilization in the population. Unexpectedly, the majority of patients referred to Complex Care are younger than 60 years old (L. Hardin et al, unpublished data, 2016). They represent a population that was previously invisible to us because of their lack of engagement with primary care services, lack of insurance, lack of participation in care management initiatives, or because of connection to a primary care system outside of our hospital network, despite using our system for their hospital care. They fall between the cracks of traditional data analysis sources such as commercial payer data, yet represent a significant portion of the hospital business (700 high-frequency patients represented 10% of the volume of hospital business in 2012). They are the face of the young dual eligible population, new Medicaid subscribers, and the uninsured, who have traditionally been left out of comprehensive population analysis data. A core competency of the intervention provided by the Complex Care Center and embedded in the Complex Care Map tool is a 10-year review of the medical record and a comprehensive root cause analysis of what drives high frequency or instability in the patient’s plan of care. Through this analysis, several themes have emerged that are rich with opportunities for policy change or system redesign (Table 1).