Katharine Royer, MSc, BSc and Carolyn Junior, BSc

1
Superutilizer Success Preventing
rehospitalizations of a patient with uncontrolled
diabetes
Katharine Royer, MSc, BSc and Carolyn Junior, BSc

• The Where Camden, NJ
• Population 77,000
• 42 live below poverty line
• 20 of patients account for 90 of
• healthcare costs

The Why Systems-Based Learning
Failures Successes
Provider relationships Education Medical Day Programs MANNA referral process Family motivation Non-profit corporate relationships

• The Who Julia
• 57 yo who lives in North Camden with two sons
• Worked as instructional aide for 18 yrs

Medical History/Diagnoses Reason for recent ER visits/admissions
Uncontrolled type 2 diabetes Bilateral amputee Coronary artery disease Gastroparesis Anxiety/depression Nausea/vomiting Abdominal pain Uncontrolled diabetes Lack of social support Anxiety/depression
Home Visit
Clinical Coordination
Social Coordination
Specialist Visit
Caregiver/Family Coordination
Phone
Medical Appointment Scheduling
Community
Medical Transport Planning
Hospital
5
6
3
10
7
1
4
3

• The How Utilization/Cost Data
• 6 Months before intervention
• 3 IP Stays17,600 cost in receipts
• 2 Months after intervention
• 1 IP Stay8000 in receipts 2 ED Visits906 in
  receipts

78
83
Care Coordination (23.37 hrs)
Patient Encounters (58.75 hrs)

Intervention

• The What Our Intervention
• Enrollment in day program
• Socialization medical support
• Referred to MANNA meal delivery service
• Access to balanced diet
• Switched PCP
• Supportive relationship/patient empowerment
• Increased HHA hours
• Diabetes management
• Home Depot Wheelchair ramp donation
• Safety for getting in/out of house

IP
IP
Acknowledgements CMMI Team Awesome Jason Turi
(RN), Angel Mitchell (LPN), Raquel Medina (LPN),
Sharine Eliza (Community Health Worker), Bill
Nice (Intervention Specialist), Kelly Craig
(Director of Care Management Initiatives) Bill
Elizabeth at Home Depot, Delran, NJ Rebuilding
Together MANNA Generations Plus
5
IP
4
Length of Stay (Days)
3
IP
2
ER
ER
1
Feb. 26
Mar. 3
Dec. 13
Dec. 16
Dec. 27
Sept. 28
2013
2012