This resource describes the Super Utilizer Project, a collaboration between an integrated health care organization and a baccalaureate school of nursing.
- The goal was to help patients with complex needs through the use of a student coach model, helping patients to improve follow-up with primary care physicians and reduce inappropriate ED use.
- Coaching involves providing feedback to help guide individuals to develop skills and self-confidence. The student coaches provide clients with disease prevention and health promotion education and assistance specific to the clients’ unique health care needs.
- The project was grounded in the theoretical frameworks of servant leadership, caring theory, and transtheoretical model of behavior change. These theories gave the students a foundation for showing the patients that someone cared about their health outcomes and their needs.
- First-year outcomes for the project were encouraging, with the total number of emergency department visits for 23 patients decreasing from 710 annually to a projected 510 annually. The total costs incurred decreased from $2.45 million annually to a projected $1.5 million annually.
- Ideas for improvement include addressing the termination process of the coaching relationship to avoid causing emotional distress.
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Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
- What does the “student coach model” involve, and what are its benefits?
- What’s an example of a project that used this model with promising results?
Level of Evidence
PromisingWhat does this mean?