Collaboration to Address the Needs of Super-Utilizers

More than 60% of our health care dollars are spent on tending to the sickest 5% of our population. Sometimes called “super-utilizers” due to their frequent use of hospital emergency departments and inpatient services, these individuals are characterized by compounding chronic conditions, mental health issues, and substance abuse, along with social stressors such as homelessness, economic insecurity, and lack of or absence of social support. As service providers, we all work with and often jointly serve these complex clients, yet they continue to falter.

We can achieve better outcomes for our clients at lower costs by coordinating our services more efficiently and effectively through collaboration. Through a $45,000 grant from the Practice Change Leaders for Health and Aging, a national program funded by the Atlantic Philanthropies and the Hartford Foundation, the Marin County Aging and Adult Services invites you to take part in creating Project Independence Plus (PI+), also known as the Collaboration to Address the Needs of Super-Utilizers. PI+ is a transition care program that targets the super-utilizers with the goal of preventing hospital 30-day readmission post-discharge, thus improving patient outcomes, reducing health care costs, and improving population health.

The coalition presents an opportunity for health care, mental health, social services, and public health to gather for the first time and explore the creation of a well-coordinated wraparound service for all in Marin County. By working together, we can create an innovative program that demonstrates reduction in health care costs while improving patient outcomes.

For more information please contact Ana Bagtas, Aging and Adult Services Program Manager and 2015 Practice Change Leader at 415-473-6947 or e-mail abagtas at marincounty dot org