When my mind considers the work of the Lehigh Valley Super Utilizer Partnership (LVSUP) I am hopeful. How fortunate we are to live in a community that accepted a vision for a community based solution to a perplexing and important healthcare concern. This demonstration project has been filled with people and organizations that persistently, patiently, and hopefully worked through all the negotiations, re-thinking, and conversations it took to get to the point we are at in June 2015. Not necessarily where we will be, say, in September, and definitely not where we hope to be in July 2016 or further in the future, for sure.
This preliminary report of the Lehigh Valley Super Utilizer Partnership (LVSUP) Demonstration Project, “Sustainable High-Utilization Team Model” reflects the progress achieved to date in developing an innovative care management strategy for high-cost, high-need populations from low-income communities in the Lehigh Valley. One of four funded sites across the country, Neighborhood Health Centers of the Lehigh Valley’s (NHCLV) model, an adaptation of Dr. Jeffrey Brenner’s work in Camden, NJ, focused on very high users of preventable hospital care with a goal of developing a strategy that reduced preventable hospitalizations while improving patient outcomes. Locally, the design of LVSUP represents a small group of committed individuals with a vision for how a community solution could best support some of our community’s most fragile and often sidelined members. The funding helped move the vision from wish to reality; community has supported it since.
The work has been filled with hope, energy, and creativity but it has not been easy. The work involved is hard- for the patients, for the team, and for the system of care that are also our partners. The possibilities though are amazing to behold and we have been fortunate to witness it right here in our local community over the past few years.
We look forward to integrating this community care management model into the NHCLV scope while continuing the data and community level work started by this demonstration opportunity. We are hopeful that the larger community will also continue investing in the next phase- transitioning from innovation into a sustainable community based model that achieves positive patient outcomes while reducing preventable utilization.
On behalf of Neighborhood Health Centers of the Lehigh Valley and the LVSUP team, thank you, for supporting NHCLV as the stewards for this important work.
Funded by DHSS Centers for Medicare & Medicare Services as part of a 2012 Health Care Innovation Challenge. NHCLV was a subcontract recipient of Rutgers University, Center for State Health Policy.
The Lehigh Valley Super Utilizer Partnership (LVSUP) provides intensive outreach and care coordination for patients with complex illness who have been admitted to the hospital two or more times in the past 6 months. This program approach has been shown to improve care outcomes and reduce costs for individual patients with high inpatient and emergency department use.
Our goal is to help patients learn to navigate the complicated world of health care, strengthen connections with their clinicians, and set and accomplish goals that improve their quality of life.
The LVSUP is a program of the Neighborhood Health Centers of the Lehigh Valley (NHCLV).
The LVSUP utilizes a trauma-informed care approach to patient care. All patients complete the Adverse Childhood Experiences (ACE) survey and contribute to developing a trauma sensitive care plan. Patients that report a history of trauma have access to behavioral health services to support them in their healing and recovery. All LVSUP services and assessments are sensitive to the impact traumatic experiences have on human development, functioning and decision making. Our team practices trauma sensitive approaches with every patient encounter, focusing on honoring patient and staff safety, trust, respect, collaboration, choice and empowerment. Staff accomplish this by focusing on a relationship oriented model and treating all patients with dignity and non-judgement.
Relationship Centered Care suggests that healing occurs in the context of relationships. LVSUP staff focuses their first few visits on developing trust, understanding and communication to foster a relationship built on acceptance, dignity and respect. We believe that establishing relationships that include familiarity with our patients’ passions, experiences, living conditions and family structure assist us in providing and advocating for care that places the patient at the center. We utilize models of care and compassion to educate and support patients in maximizing their potential, achieving wellness, managing their diseases and utilizing community resources to improve their lives.
A strength-based approach views individuals as having resources to be enhanced upon rather than shortcomings to be remedied. This promotes self- determination by involving the individual in decision-making, which is extremely important for their well-being with regard to self-esteem.
The barriers that patients face are multiple and complex, requiring partnerships with various community-based organizations to address these barriers.
Traditionally, healthcare providers have committed
to cultural competency, which focuses on increasing knowledge and understanding of different cultures and how those differences impact our work with patients. Cultural humility suggests providers are responsible for forgoing stereotypes and acknowledging the uniqueness of every patient’s cultural expressions. The LVSUP utilizes cultural humility by seeking to understand the identity, needs, and preferences of patients by asking them what is important to them. Cultural humility
begins with self-awareness and a willingness to listen attentively to patients’ cultural needs and preferences. By acknowledging that we as providers may bring assumptions, prejudices, and blind spots to our work, we minimize the harm we may cause in our interactions with patients and we create an environment conducive to learning and equity.
Lydia was in a nursing home completing rehabilitation due to multiple chronic conditions and poorly managed diabetes. She was unable to be discharged due to homelessness and was unable to secure housing due to immobility. LVSUP staff was able to locate and secure an apartment for Lydia, as well as support her in enrolling in meal and grocery delivery services, securing transportation services to dialysis and medical appointments, enrolling in the kidney transplant list, and joining Community Exchange.
Dennis was wrestling with homelessness, multiple chronic health conditions, lack of transportation to medical appointments, and no social support or method of communication when he was referred to LVSUP. Once joining the team, Dennis was able to identify and achieve his goals of securing housing, food assistance, a cellphone, and medical transportation to doctors’ appointments.
Carlo was living in single room occupancy (bedroom with a shared kitchen & bathroom). While enrolled in the program, Carlo was able to secure an apartment, receive assistance with unpaid medical bills, reduce pending motor vehicle violations and fines, and receive home-delivered oxygen. Carlo also joined Community Exchange and has been contributing to his community by providing rides to his neighbors and participating in community events.
Lawrence was one of our first teachers. Lawrence presented with over 8 chronic conditions, bi-monthly hospitalizations, challenges with mobility, and unreliable transportation to dialysis. Prior to developing a team, the founding LVSUP partners enrolled the program’s first four patients including, Lawrence. When asked what was his most pressing need, Lawrence humbly responded, “a doorbell.” The partners later learned that LANta van drivers would only beep their horns when they pulled up to Lawrence’s house, despite his immobility. Lawrence’s health took a turn for the worse when he was hospitalized due to a snowstorm and LANta policy prevented the drivers from transporting patients when they could not reach the curbside. Lawrence’s subsequent ospitalization exceeded $70,000. Working with Lawrence helped the partners learn about the complications involved with working with complex patients. The team’s understanding of the need for collaboration increased through working with Angela, a social worker at Fresenius, to partner with Lawrence in recognizing his strengths, making significant health behavior changes, and achieving true success.
Health and Activation – The following data is for patients with follow up data at or after commencement
16 out of 28 patients reported an improved health rating
20 out of 28 patients reported an improvement in number of physical healthy days
13 out of 28 patients reported an improvement in number of mental healthy days
23 out of 34 patients had improved patient activation scores
ER, Hospitalization, Length of Stay
Length of stay (n=44):
6 months pre = 687 days
6 months post = 338 days
Emergency department visits (n=44):
6 months pre = 138 visits
6 months post = 63 visits
Inpatient hospital stays (n=44):
6 months pre = 155 stays
6 months post = 64 stays
When applying the Agency for Healthcare Research and Quality hospital stay cost estimates, the LVSUP has saved $773,500
28 patients have been enrolled in Community Exchange
21 patients have been active in Community Exchange from June 2014 through March 2015.
For these patients, there have been:
396 total exchanges
536 total hours earned
220.75 total hours spent
756.75 total hours transacted
7 spouses and community members have enrolled in Community Exchange::
60 total exchanges
75 total hours earned
30.5 total hours spent
105.50 total hours transacted