title: Super-utilizers get red carpet treatment.
abstract: MetroHealth Medical Center in Cleveland has partnered with two health plans to provide intensive care coordination for high-cost patients with multiple medical problems and, often, behavioral health issues. Nurse practitioners at two primary care sites provide one-on-one care coordination for super-utilizers. They assess the patients' needs, help coordinate community resources, and prepare a treatment plan that is flagged when patients visit the emergency department. The nurse practitioners meet with health plan representatives monthly and brainstorm on ways to meet patients' needs.
mesh_terms: D015897:Comorbidity; D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000592:standards; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000458:organization & administration* / Q000592:standards; D006300:Health Services Misuse / Q000517:prevention & control*; D006801:Humans; D007373:Interinstitutional Relations; D008329:Managed Care Programs / Q000458:organization & administration / Q000592:standards; D008484:Medicaid; D028642:Persons with Psychiatric Disorders; D017146:Models, Organizational; D009722:Nurse Practitioners / Q000458:organization & administration / Q000592:standards; D009723:Nurse-Patient Relations; D009820:Ohio; D019982:Organizational Case Studies; D011320:Primary Health Care / Q000379:methods / Q000458:organization & administration*; D012959:Socioeconomic Factors; D014481:United States; D000078329:Workforce