“How do we do a better job with our complex highest utilizing patients?”
That was the question at the heart of the research project proposed to Berkeley Social Welfare by Sutter Health-Alta Bates Summit Medical Center Administrative Supervisor for Social Work and Berkeley Social Welfare Field Instructor Tracy Schrider (MSW ’89). It was also the very issue that Schrider and her organization had been working on prior to the invitation from the School for project proposals to advance the learning needs and research skills of MSW student interns, and, even more importantly, help inform service provision to Alta Bates Summit patients.
In 2015, Schrider had enlisted the aid of then-Berkeley Social Welfare student Kamilla Maciel Tien (MSW ’15), who was serving her field placement at the medical center. Under the auspices of the new Camden Coalition for Health Providers partnership, an N=1 case study was launched in an attempt to discern the larger picture of what was happening with the hospital’s “hardest patient.” Maciel Tien created an ecomap, which Schrider describes as “a graphic depiction of all the different hospitals and case management places for homelessness and substance use” that were being utilized by the patient. “Kamilla and I worked from the questions, ‘How do you take a patient experience by collecting the data and telling the story of it?’ and ‘How do you graphically depict it in a compelling way?’”
What they uncovered spoke volumes about how paying close attention to the experience of one patient can shed light on the changes needed in a fragmented healthcare system. The patient had logged 80 emergency room visits in a six-month period as well as nearly 900 ambulance rides over three years. The costs were astronomical, but more significantly, the patient’s most serious and ongoing needs were not being met. Schrider notes that this was exacerbated by the lack of coordination among all the centers frequented by the patient. “We would be referring her to one case management service but she was already involved with another. She had too many referrals.”
An important outcome is that since then, after gathering the community partners for a case conference in May 2015 and working together, the patient now has housing and coordinated case management, resulting in zero ED visits to Alta Bates Summit in the last year.
Schrider says she knew that a larger examination of the aggregate data could yield important findings about the “high utilizers” of emergency-room and in-patient services. She participated in the Fall 2015 Berkeley Social Welfare roundtable for MSW students, using slides and some of the data prepared by Maciel Tien to “sell” the Alta Bates Summit research project to potential interns. Ultimately, Rina Breakstone (MSW ’16), Minah Clark (MSW ’16), Jenny Lam (MSW ’16) and Yvonne Yung (MSW ’16) were the students to sign on to the project.
To begin this massive undertaking, the MSW students and field instructor worked with Alta Bates Summit’s data and strategy department to obtain a dataset for all the inpatients and medical-surgical patients, including those from the emergency department, from July 2014 to July 2015. Once they gained access to the information, the MSW students de-identified their subjects by patient needs to discern who the high utilizers were, how they were using the services and where systematic failures looked to be occurring based on the fragmentation or disorganization of the larger healthcare infrastructure. “We’re often focused on patients who are in the norm, but where we can learn the most are the outliers,” says Schrider.
The project’s dataset required combing through records for thousands of individuals, resulting in the students’ research skillset developing in numerous ways. Patient privacy was the highest priority, so the data had to be kept completely onsite. The students also benefitted from resources and partnerships within Alta Bates Summit, particularly with the lead researcher in the Research, Development and Dissemination (RD&D) division. “Social workers can’t do this work alone,” explains Schrider. “We need to understand the power of data to be able to advocate for programs and evaluation. We need these partners to cultivate methodologies that are grounded in good and correct data.”
Breakstone, Clark, Lam and Yung’s findings were remarkable. Working with the thesis, “In order to provide appropriate care and reduce expensive and ineffective use of the hospital, we must first understand the demographics and needs of this population,” they surmised that two distinct patient groups were representing the “greatest burden” in terms of resources to Alta Bates Summit — the “high utilizers,” defined as patients with 10 or more ED visits within a 12-month period, and the “super utilizers,” who had 10 or more ED visits as well as five or more inpatient admissions within 12 months.
The student team learned that the super utilizers represented just five percent of the patient population but an astonishing 69 percent of the cost. During the timeframe, the high and super utilizers collectively accrued costs of more than $11 million.
Observing that “individuals in this patient population often face multiple complex social challenges, ranging from mental illness, joblessness, homelessness, substance abuse, early-life traumas, social isolation to poverty and unstable or chaotic living conditions,” the students’ recommendations included exceptional interdisciplinary coordination within the hospital, stronger coordination with community partners, the creation of a centralized housing registry that prioritizes these patient populations, enhanced cultural competency to better serve patient needs and a focus on reuniting patients with their families.
In recognition of Breakstone, Clark, Lam and Yung’s dedicated efforts and hard work in collecting and analyzing the data, the School of Social Welfare selected their final paper, “High Utilizers and Super Utilizers at Alta Bates Summit Medical Center: Who are they and how can they be supported?” for the Excellence in Social Work Research Award last spring.
The effects of their research also continue to resound at their field placement site. Schrider says that while Alta Bates Summit’s RD&D is in the process of validating the data, the findings are informing and influencing strategic thinking. For example, the medical center is currently partnering with Housing First and community agencies to help focus on these patient groups.
“What does it mean?” asks Schrider. “It means we need to be deploying resources, strategy and targeted interventions. We need to segment that population and say, ‘This is not just an assembly line of people.’ We can’t do the same thing for everyone. We need to consider some are much more complex patients, and ask, ‘How do we wrap around them? How do we have better partnerships with the community? How do we do handoffs? How do we have a shared-care plan?’”
One significant result of the learnings, Schrider notes, is that Alta Bates Summit pioneered cross-hospital Emergency Department Information Exchange software in March for sharing data with other area hospital EDs.
The Berkeley Social Welfare graduate and longtime field instructor adds, “I am very committed, particularly in this historic moment, for social workers to be savvy about delivering trauma- informed care across settings.”
For Schrider, the dataset encompassing the long-term patterns of some of the most difficult challenges of vulnerable patients was another important way “to connect” the MSW interns she supervises to the profession’s “mission and vision.”
“It’s the why of the work,” she says.