Improvement Happens – Learning to Better Care for “Super-Utilizers” at Denver Health

Key Questions Answered
  • What is the ideal primary care clinic design for people with complex needs?
  • How did one health system establish such a clinic?
  • What has Denver Health learned from its experience with the clinic?
Key Themes and Takeaways

Denver Health received a Centers for Medicare and Medicaid Innovation Award to develop an intensive outpatient clinic (IOC) to improve care and lower costs for patients with complex needs. In this resource, co-principal investigator Dr. Holly Batal explains how the clinic works in an interview.

  • Using a hospital census system, the clinic enrolls patients who have had three or more hospitalizations in a year. The census system allows staff to invite patients to participate during their hospital stay.
  • Features of the clinic include longer appointment times, flexibility for patients to seek care when they’re ready, and much more support from social workers and patient navigators.
  • Patients are not meant to stay with the clinic forever, but rather the IOC encourages them to move back to regular primary care when they’re ready.
  • Health outcomes and cost savings were still being studied at the time of the interview.
Michael Hochman
Population Addressed
Adults Under 65 with Disabilities
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Level of Evidence
Expert Opinion
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