At SBH Health System, the top 50 ED utilizers logged over 2,500 visits and nearly 200 hospital admissions in less than a year. Many of these patients suffer from complex physical and behavioral health issues, exacerbated by lack of basic necessities like food and housing.
SBH joined the DSRIP Medicaid Accelerated eXchange (MAX) Series, a population-based performance improvement initiative led by NYSDOH, to launch a targeted program to identify and connect these super-utilizers to more appropriate and supportive services. This is a critical need for SBH, especially as it launches BPHC’s ED Care Triage project. In February, 2015 clinical leaders from SBH and BPHC began meeting with representatives from other PPSs to develop plans for this initiative, and have met quarterly to present updates and receive guidance and best practices.
Since the first MAX Series meetings, SBH has compiled a list of the highest ED utilizers and developed a protocol to flag and divert them. Because up to 70% of super-utilizers are homeless, SBH is partnering with supportive housing providers
at BronxWorks and Bronx Crisis Respite Center – both members of BPHC – to receive patients who are visiting the ED due to a housing or mental crisis. In addition to helping high-risk patients, these new systems will also allow SBH to get a head start on implementation of the ED Care Triage project. SBH will present a final assessment
of this initiative in September, 2016.