The readmissions-superuser fix: Help patients before they become sick

To prevent readmissions among so-called hospital superusers or frequent fliers, some healthcare providers take on initiatives that address the complex social factors that cause patients to seek care in hospitals, according to the New York Times.

A 2014 study found socioeconomic factors, such as employment status and education levels, are major drivers of readmissions. Initiatives to address superusers and their reasons for returning to the hospital exist in 26 states thus far and are run by a combination of state and federal officials, insurers and providers, according to the article. For example, Portland, Oregon, health outreach workers help connect patients with essential services and goods such as driver's licenses, bus tickets and blankets, while in Philadelphia, community health personnel help diabetic patients with grocery shopping.

One Minneapolis pilot program encompasses 10,000 low-income patients who are eligible for Medicaid since the state expanded its program under the Affordable Care Act. It proactively targets patients' conditions to prevent them from spiraling into expensive long-term medical issues. This means Hennepin County social services workers help cover outstanding utility bills so that diabetic patients don't lose electricity and their insulin stays refrigerated.

Since the program began in 2012, Hennepin County medical costs are down an average of 11 percent per year, with some of the most drastic savings among the 250 patients the program was able to connect with permanent housing. "We had this forehead-smacking realization that poverty has all of these expensive consequences in healthcare," Ross Owen, a county health official involved in the initiative, told the Times. "We'd pay to amputate a diabetic's foot, but not for a warm pair of winter boots."

However, it's not clear if such programs are sustainable on a broader scale, particularly since they depend on the willingness of private providers to foot the bill for those socioeconomic factors that bring superusers back to the hospital. Proactively understanding the social determinants of health problems among vulnerable populations is a major challenge as healthcare shifts to value-based care, according to a panel at the 2015 Congress of the American College of Healthcare Executives, FierceHealthcare previously reported.

To learn more:
- read the New York Times article

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