Dr. David Buck, president of the Primary Care Innovation Center, meets with a program patient.
Houston Fire Department paramedics knew Mr. B’s home in Houston all too well. In just seven months, Mr. B or his mom had made 22 calls to 911. The 42-year-old was frail, his eyes were sunken and his skin was a terrible shade of grey. For several months, Mr. B’s mom had tried to keep his weight up by feeding him beans, but he kept getting sick. Since he didn’t have a doctor, they called 911 for an ambulance ride to the emergency room.
“Without a primary care physician, Mr. B had no direction on how to improve his health,” said Dr. David Buck, a professor of family medicine at Baylor College of Medicine. “The ER was his only source of medical care.”
Mr. B is part of a small, but extremely costly group known as “frequent flyers” or “super-utilizers” – patients who have visited the emergency room at least 10 times in one year. In Harris County, there were more than 6,000 “super-utilizers” in 2013.
“They’re the costliest and most vulnerable patients, yet they’re not getting the care they need,” said Buck. “The U.S. spends $2.8 trillion dollars on health care, half of that amount ($1.4 trillion) is spent on patient’s like Mr. B who account for just 5% of the general population.”
That’s why Buck founded the Patient Care Intervention Center (PCIC) in 2014. The group’s goal is to identify a group of super-utilizers, get to know their stories and then coordinate their health care. The PCIC team includes HFD firefighters, case workers and nurses. Each week, team members coordinate each patient’s chronic medical needs by making home visits and directing them to an appropriate primary care physician instead of the ER. The team also goes along on doctor’s appointments, helping ensure patients’ needs are acknowledged and addressed.
PCIC’s program is already working. Among participants in the PCIC program, there’s been a 56% reduction in 911 calls, 67% reduction in ambulance trips to the ER and a costs savings of $114,640. In addition, the PCIC team has collected extensive data and records from 13 community partners to help identify more super-utilizers.
Mr. B was one of the first patients in Houston to sign up for PCIC’s program. Although his condition is rare, PCIC’s team helped identify that his mother’s use of beans was a key factor in driving his health crises. Following an appropriate nutritional diet and with a few changes in medications, his health dramatically improved. Now, he can walk without assistance, he’s happier, and no longer relies on ambulances or hospitals.
“He has much better health at a much lower cost,” Buck said. “Coordinating his care and addressing the root cause of his ER visits is an example of how an effective safety net can work.”
“The improvements to the well-being of these vulnerable patients are life changing,” said Elena Marks, EHF’s president and CEO. “By working at a systems level, the cost savings are passed on, resources are now used more efficiently, and the capacity of the entire healthcare system expands.”
EHF’s $150,000 grant will help PCIC develop a county-wide care coordination program for similar “super-utilizers”. The program’s goal is to coordinate care for around 150 patients by December of 2016, reduce ER visits by at least 30%, and add more hospitals and partners to the project.
Right now, participants in PCIC’s coordinated care system include the Houston Fire Department, Harris Health System, Houston Police Department, Memorial Hermann Hospital System, Healthcare for the Homeless-Houston and more.