Dr. Eleanor Barbera

I was flying home after visiting some family elders last week (a story itself perhaps for another time) when I happened upon a Kaiser Health News article about “super-utilizers” of emergency room services.

Research on Medi-Cal, California’s state health insurance for those with limited income, found that 1% of the patient population accounted for about one-fourth of the healthcare spending.

The reason: Super-utilizers were more often homeless and had substance abuse and mental health problems.

This echoes my experience working as a case manager for a managed care organization years ago. For the particular account I was working on, the mental health managers had access to both the medical and mental health data.

My main observation was that those with the highest medical costs were also those who had been in and out of rehab for substance abuse. The problem was that because our company was a “mental health carve-out,” with HIPAA-protected information, we couldn’t share that information with the medical team.

“Ask them if they’ve been drinking!” I wanted to shout, when I saw they were getting readmitted to the medical hospital for the third time in two months.

It’s a question we might consider asking in long-term care too (along with checking on psychiatric medications). The “super-utilizer” problem affects us in ways that may be less obvious but just as costly.

The super-utilizer in long-term care

Our super-utilizer of services is a resident who exhibits behaviors due to a mental health or substance problem that results in a series of staff meetings and discussions that takes time away from other residents.

It could be someone who needs repeated psychiatric hospitalizations because of psychiatric medication changes during the transition from home to medical hospital to skilled nursing, or an individual ready to be discharged after rehab but difficult to place due to comorbid physical and mental health needs. (A problem also faced in psychiatric hospitals, by the way, when a now-stable patient has comorbid physical health needs.)

Families can be super-utilizers of services. Consider the time-consuming challenges when a substance-abusing relative is found to be taking money from a resident or a discharge home is deemed unsafe because of a mentally unstable family member. I guarantee that’s not a one-meeting decision.

Reducing expense of super-utilizers

In the Medi-Cal program, they found great success in decreasing the costs of super-utilizers by closely monitoring those individuals through an intensive care coordination program. According to the article, “The program saved $14 million in healthcare spending for just those 37 people over two years, compared with the two years prior to the launch of the program.”

While LTC providers probably aren’t tracking costs as closely as the Medi-Cal program, it’s likely that a small number of residents are incurring rehospitalization expenses or using a relatively large amount of resources such as staff time. Some LTC super-utilizers have higher-than-average medical needs, but many of them have behavioral health and substance abuse problems, which could respond to the management ideas listed below:

• For residents with psychiatric histories, contact the community psychiatrist to confirm their medications. It’s not uncommon for psychiatric medications to be eliminated or adjusted during a hospital admission, leading the resident to become unstable during their rehab stay. If the psychiatrist is unavailable, family members or the residents themselves may be able to provide the needed information.

• Establish a working relationship with a geriatric psychiatry unit at a local psychiatric hospital. Geriatric psychiatry units are attuned to the needs and comorbid medical challenges of elders. (If all your residents are returning from the psychiatric hospital with baby dolls in their arms, it’s time to reassess your options.)

• Increase the frequency of monitoring of challenging residents by the entire treatment team, including the consulting psychiatrist, psychologist, and attending physician. It’s especially important to communicate information about behavioral changes gathered from aides and nurses across shifts. Super-utilizers can be assessed regularly at change of shift and team meetings can be assembled when necessary.

• Ditto for challenging families. The close involvement of the social worker and, if needed, community support systems will also be beneficial.

• Convene medical ethics meetings for difficult cases.

• Immediately refer young residents and those with psychiatric and substance abuse histories for psychology and psychiatry evaluations. This is more likely to happen if admissions staff put in the referral as soon as the resident is admitted.

• Have policies and procedures in place for alcohol use, cigarette smoking policy violations and other challenging behaviors.

• Provide access to Alcoholics Anonymous meetings either on-campus, off-campus, or via the telephone. Many substance-abusing residents have prior AA experience which provides continuity between facility and community. In addition, the philosophy of the program encourages appropriate behavior so that they’re hearing the message from a neutral source compared to the treatment team.

Reducing the costs of LTC super-utilizers first requires recognizing them as such. Applying consistent team efforts — including mental health and substance abuse resources — increases the likelihood of successfully meeting their needs and decreasing expenses.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident’s Guide, is a 2014 Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the 2014 American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with nearly 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.