Qualis Health Emergency Room High-Utilizer Program Achieves Results

Individuals with complex healthcare needs tend to incur disproportionately higher costs than others, and their healthcare needs are often exacerbated by social determinants of health, such as lack of housing or transportation. Qualis Health’s Emergency Room High-Utilizer Program was established to address the challenges of care for high-utilizing Medicaid members in Anchorage, AK. Those high ER utilizers represent 3% of the state’s Medicaid population but 22% of overall hospital ER costs.

Working with the state, Qualis Health designed a program to provide in-person case management to a targeted population of high ER utilizers to reduce frequent ER use for issues better treated in a primary care setting. The program implemented a team-based approach, which included a licensed clinical lead and two community health workers, with further support by a staff psychiatrist, medical director, and RN case manager consultants. Primary interventions in the program included:

  • assisting members to develop a medical home relationship with a primary care provider and accompanying them to appointments
  • teaching self-management skills and medication management
  • coordinating with behavioral health and social service providers, including shelter and permanent housing programs, transportation assistance, and food security resources
  • developing an after-hours plan to reduce avoidable ER visits during nights and weekend hours

Preliminary program results using claims data indicated that ER and inpatient visits and associated costs were significantly reduced post intervention:

  • 39% reduction in ER visits
  • 49% reduction in ER costs
  • 66% reduction in inpatient visits
  • 81% reduction in inpatient costs

This program was recognized as the national winner in the 2017 DecisionHealth Platinum Awards in the Care Coordination category.