How do you handle High Utilizers?

[MoriahRoseRN]

How do you handle High Utilizer's in your healthcare system. Patients that come in for every little sniffle, ache and pain, and or use the the Er as their healthcare access. In my clinic we don't have high utilizer's of the ER, but just walk in at their leisure and expect to be seen.

I work as a case manager, and it is so new to me. I have been told I need to come up with a process to curtail the high utilzers, and really, I am so lost . I am trying to wing it. If anyone has any suggestions I would so apprecitate it. Thanks!

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

You're kinda stuck. They can come in a thousand times complaining of sniffles, and the thousandth time they could die on you. If you don't give them good care EVERY time they come in you're taking a big chance.

Best I can suggest is telling them they need to find a primary provider because they'll get more consistent care. Don't give meds, especially refills, for any longer than it'll take for them to find a primary provider. Reinforce the need to find a primary provider, but NEVER deny them care. Give them a list of primary's, even suggest they see a specific one. Your doc could call one and get the process started for them, then tell them this primary is expecting their call.

That's how ER's handle it. Maybe someone else has some better advice for you. Come right down to it, it's not a nurses problem. Doctors, bean counters maybe, but you're the patient's advocate. Not the docs or book keepers advocate.

[fungez]

I had that issue as well when I worked ER. I'd get all indignant "you're here for that?" Having never in my life gone to the ER I thought it was for, you know, actual emergencies. It's annoying, I know, but getting frustrated about it just causes you stress. It won't change the situation one iota. Try not to think about it.

[TDCHIM]

1. How much information do you have about these people? Just raw numbers? Month-to-month, year-to-year fluctuations? What is your functional definition of a "high utilizer"? How often do they have to show up before you or your organization consider them as such? How about age? Insurance status? Last time each one visited an actual primary care physician? That data will at least help you get started, although there's a lot more you could probably benefit from obtaining.

2. The best option after finding all that information is to just ask your high utilizers themselves! Select a random sample of your high utilizers to be personally interviewed on-site. Ask questions about whether each one uses a primary care physician at all and to what degree cost is a factor in that decision and (in the case of those who do have a PCP) in how often s/he visits the PCP (on a one to ten scale).

I would also suggest you compile a list of options you and any collaborators in this project think will help move high utilizers into the arms of primary care providers. You could include basic things, like contact data sheets for nearby physicians accepting new patients (which are more useful and more likely to be used if the sheet lists whether each doctor accepts Medicaid, etc.), follow-up phone calls to patients reminding them about the contact sheet and asking if they have any questions, etc. I'd also touch base with your local job and family services folks to gather information about other resources available for those in need of care and include some of those options on your list. Then you can ask your high utilizers how much (on a one to five or ten scale) each option would help them or persuade them to pursue treatment through a PCP.

3. Once you have all of that information, analyze it. Check for trends (are your older patients more in need of intense social assistance options? Are recent immigrants expressing fear of seeking out governmental help or a regular relationship with a PCP?) - there's a lot of terrific software out there that can help you do this easily. Try to find the biggest bang for the buck options, but be very, very cautious of implementing any idea that could in any possible way limit the patient's access to care at your facility.

I don't know how large your clinic is or what your staff is like, but if you have HIM staffers (a RHIA will probably be your best bet), I'd suggest you ask them for some help pulling this together.

I hope at least some of that helps!

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

I've infinite respect for those who work elsewhere, because ER is all I can do. In the ER a wise MD once told me something that has brought me great peace. "Sometimes the hardest part of the job is forgiving the patients."

[MoriahRoseRN]

TDHIM,

I work for a military facility. The High Utilizer's are mainly active duty military that already are empaneled to doctors, but are visiting for equal to or greather than 10 visits per year. I have to see if they are suitable for case management, or should be referred to a specialist. Which most have already been to. Most of them to me are not really having any real healthcare issues, but are just going in for every little thing.