Super Utilizer Project
Mountain-Pacific Quality Health works with communities in Montana to reduce unnecessary hospital readmissions, especially among older adults. Contracted by the Centers for Medicare & Medicaid Services (CMS) to do this work, we have a wide range of partners and stakeholders that helps make sure patients get quality and affordable health care.
We are now working together to form community outreach teams called Complex Care Models to meet the needs of high-cost, high-needs patients known as “super-utilizers.”
What are Super-Utilizers
Super-utilizers are patients that are resource intensive—they have more emergency department visits and more hospital readmissions. These patients also rely more on community services.
What are Complex Care Models?
Complex Care Models are community health teams that provide care to complex patients needing more primary care and community support services. They also help super-utilizers deal with the social challenges that keep them from getting better care.
Complex Care Models take care beyond the clinic and hospitals—they provide care to a select set of patients in their home setting.
What Type of Patients are Considered
Complex Care Models help patients who:
- have had two or more inpatient admissions (within six months)
- have had two or more observation stays (within six months)
- have had three or more emergency department visits (within six months)
- have had six or more urgent care visits (within six months)
- can benefit from more coordinated primary care
- have medical problems that can be prevented, such as diabetes
- are not end-of-life
- do not have conditions that will continually get worse
Where are we Focusing Efforts?