In 2013, the Center for Health Care Strategies, Inc., hosted a “Super-Utilizer Summit” to explore how Medicaid could promote models to improve care and lower costs for individuals whose complex needs are not well met by the health care system. The resource covers common themes and key recommendations from the Summit, with brief case studies and appendices with educational resources for states and policymakers.
- Strategies fall into three areas: data collection and analysis to identify a patient population; care teams and care management; and integration, replication, and sustainability of programs.
- Most care teams include some combination of nursing, social work, and community outreach expertise.
- Interventions typically include extensive outreach, a 24-hour on-call system, and medication management.
- Teams tend to “front-load” social services; that is, case managers or social workers often make the first connection with the person in need of services, to try to meet basic needs such as housing first.