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Addressing the needs of high users of the health system: where do you start?


Across Canada, health system leaders are recognizing the need to provide more effective and more efficient care to the highest users of the health care system.  In December 2012, the Ontario government launched an ambitious Health Links strategy to better address the needs of the top 5% of health system users, who consume two thirds of the total provincial health budget. In October 2013, the Saskatchewan government announced the launch of pilot initiatives in Saskatoon and Regina to target the top 1% of patients who consume an estimated 1/3 of all health care resources in each region. Similar initiatives are underway in British Columbia and Alberta.

While these government-sponsored strategies are new, high user initiatives are not and there is something to be learned from those launched at the local level in Canadian communities over the past decade. One of these is the Défi Santé initiative in Quebec which was supported by the Canadian Foundation for Healthcare Improvement.  The project focused on applying emerging best practices from international literature to make tangible improvements in care for the high users of the Sainte-Agathehealth care network in Quebec. At project initiation, the network was experiencing significant financial problems and capacity issues. The 115 acute bed network was operating at 115% capacity with a shortage in nursing staff and a reliance on over-time staffing.

The key question being tested in the project was: “Instead of simply cutting services or changing the staffing mix of the health network, is there a way to sustainably reduce both the patient volume in the emergency room (ER) and bed utilization?” Accomplishing this task required the network to focus on those who disproportionately used the ER and were admitted for treatment – the top 5% of patients.

The Défi Santé approach involved a detailed action plan, but at its heart it focused on realigning internal nursing capacity to have two dedicated case managers focus on improving care for the frequent user cohort. This approach was based on the UK’s NHS community matron model and focused on transitioning patients from chronically ill to chronically well5. Integral to this approach was results tracking and performance monitoring in order to adjust care management strategies and case manager case loads. The initiative also began to introduce the Wagner chronic care model across the organization more broadly.

The initiative has been enormously successful, with reductions in the use of the emergency department and acute care beds, as well as improvements in the patient health status. Today, the project has been implemented, or is in the process of being implemented in more than 40 health care organizations in Quebec.

Through Défi Santé, there are learnings that may be useful for other provinces as they redesign care to better meet the needs of high users of the health care system.

Lesson #1: Stratify your high user population into frequent user and long-user sub-populations

The high user population is actually made up of individuals with differing health problems, demographic characteristics and utilization profiles.  It is essential at the outset of a high-user initiative to recognize that the high user population is actually composed of two distinct groups of patients: frequent users (frequent visits to the ED and repeated hospital admissions and long users (prolonged stays in hospital, including patients waiting for an alternate level of care). While both of these sub-populations have poor health status and consume a significant amount of health system resources, they have fundamentally different challenges and require very different clinical and administrative interventions.

The Défi Santé experience shows that it is much easier to improve care and reduce utilization for the frequent user cohort as compared to the more intractable long user population. There is a much greater return on investment in initially focusing organizational capacity on improving care for these frequent users.

Lesson #2: Think Big (or “big enough”)

The Défi Santé experience suggests that organizations can receive a significant return on investment from tackling frequent users only if a sufficiently large patient cohort is included in the initiative. For example, reducing the utilization of 25 frequent users may improve the health status of those individuals, but it is insufficient to allow local healthcare providers to fundamentally realign capacity. Modeling is required at the out-set of a frequent user initiative to determine the appropriate cohort size and the performance improvement required to deliver a clear return on investment.

Lesson # 3. Clinical buy-in requires targeted engagement based on timely, meaningful patient-level data

Frequent user initiatives cannot succeed without the active participation and leadership of clinicians.  The same data that compels administrative leaders to act, however, is insufficient to mobilize physicians and other clinicians. The Défi Santé experience found that physicians became engaged when they were provided with patient-level data so that they can review the clinical history of individual patients.  It is critical that this information is accurate, timely and actionable.  If the data is a year old and many of the identified patients have died, it is clinically meaningless and can actually undermine credibility.  For this reason, while an initial portrait of frequent users can be pulled from administrative databases, IT solutions that provide up-to-date, patient-level data on frequent users can greatly improve physician engagement.

Lesson # 4: Sustaining progress requires ongoing monitoring and management

Managing frequent users is like air traffic control – once you have dealt with the current priority patient another immediately appears on the horizon. The Défi Santé initiative addressed this by dedicating nurse case managers with improving the care coordination for a roster of patients. Patient level data was monitored continuously with new frequent users added to the roster replacing patients who have been successfully stabilized. This was made possible by an IT solution, Med-GPS,  that allowed access to patient data in real time. This solution allowed monitoring of what was happening with the current frequent users and at the same time flag the potential next frequent users to reduce the likelihood that they would become future frequent users.

As provinces across the country launch new initiatives to address the needs of high users, we hope some of these experiences and lessons learned may be helpful to others on the same path.

Jean Mireault is the Chairman and Vice-President of Clinical Affairs for MediaMed Technologies. France Laframboise is a consultant in clinical performance and integrated management of chronic conditions. Tom Closson is president of Tom Closson Consulting.

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7 comments

  1. Natalie Warrick

    What would be the best approach for dealing with privacy related issues around sharing of sensitive client information across agencies, providers and systems? Can any lessons be applied from the successes of Défi Santé in dealing with privacy concerns?

    • Jean Mireault, MD, MSc

      Thank you Natalie for your question.
      It is an important issue and its solution needs to be planned out right from the beginning. Over time, we have found two different answers to this question, the first being to get each patient to sign a consent form during their ED visit. This consent form allows us to connect them with their family doctor. The second way, and probably the most important one, is during the face to face contact with each patient for which we have designed both a questionnaire and a consent form. Through this consent form the patient agrees to have their sensitive information shared amongst relevant healthcare providers.
      Different organizations involved with our model have tested this important issue with their legal advisers and no problems have been raised.
      Hope this answers your question.

  2. Sue Jones

    I would like to know if there are any concrete decreases in the use of ED’s and hospital admissions and can you interpret that into an amount of dollars saved? As part of the strategy is the intention to move funds from hospitals to community services in order to keep people at home and has that happened?
    How long has this initiative been underway?
    From lessons learned how long in terms of years does this type of change take to plan, implement and sustain?
    Did the initiative in Quebec involve patients and families?

  3. Jean Mireault

    Hi Sue,
    I would like to begin by thanking you for your questions as they represent some of the common inquiries we receive when speaking with people about frequent user management projects.
    Based on the projects we have done in over 40 healthcare institutions across Quebec in the last years, we have seen significant decreases in both ED visits and Hospital admissions. In example, one of the major projects that we worked on, named Défi-Santé, resulted in the reduction of a 15 bed equivalency within a two year time period. This reduction significantly helped address major issues related to overcrowding in the Hospital. Furthermore, the bed reduction aided the Hospital, as a whole, as it enabled them to avoid a 2.5 million dollar annual deficit.
    One of the main strategies for this type of a project is to reduce Hospital focus. What tends to occur, based on our experience, is that more care is given within the community. This is possible due to the moving of human and clinical resources towards the community. It is also important to note, that even though there is an evident transfer of care from Hospital to community, overall less care is needed by the population, as frequent users are managed better, their health improves. Some projects have actually resulted in a decrease of care needed at the Hospital as well as in the community. Thus, proving that patients are simply experiencing better patterns of health.
    The project mentioned above (Défi Santé) first began in 2006-2008; it was the baseline for many other projects including impactful initiatives completed in collaboration with 3 separate health authorities. This methodology has become a major transformative component for most of our clients, and has helped them manage not only frequent users, but long users as well.
    The duration of this type of project depends on two critical elements, Leadership and Motivation. Leadership involves both financial support and the involvement of senior executives that will enable the project to move at a faster pace. Secondly, the motivation of the team as a whole plays a large role in the development of the project and its success. With both leadership and motivation, it should take no longer than three months to get the first patients on board. Nevertheless, it can take up to two years to see significant clinical and financial results. In order to keep track of this, we always measure the current cost of frequent users, which allows us to analyze the ROI of this type of management towards the end of the project.
    The element of sustainability in this type of a project is imperative. The way we see it, frequent user management is not a project, it can be considered a cultural/organizational change. A medical facility needs to change their way of dealing with patients and change their belief that frequent user management and chronic disease management are one in the same. For further information on this, I would encourage you to e-mail me (jmireault@mediamedtech.com)
    Without a shred of a doubt, this sort of initiative is 100% patient and family-centered. The basis of this approach is to focus on what the frequent user’s need and to try and understand the reasons for their over-utilization of clinical resources. Frequent users are those for which “typical care patterns” do not work. It thus becomes crucial to deal with them individually to discover what the healthcare system can do for them. It is a “thinking-outside-the-box” sort of strategy, one which changes with every patient. To do this a personalized care plan is developed between the patient and their family doctor.
    I hope this answers your questions.

  4. Jane Yi

    I am wondering if you feel that this model can be transferable to high users of multiple systems. Often, if a person is a high user of ED services, they are also high users of social services, police services and ambulance services.

    • Annette McKinnon

      That is very interesting idea. I heard from people at the Downtown Eastside, an overnight shelter in Vancouver, that when they started to provide storage for homeless the police reported that property crimes dropped dramatically.
      Small changes can have huge impact.

  5. Jean Mireault, MD, MSc

    Hi Jane,

    That is absolutely correct. In fact, we consider this relationship an important element in defining who the high users are. Analyzing ED visits is only one element of our methodology. We understand and have seen that improving the health of these individuals is not only beneficial to the healthcare system, but to the community as a whole.

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