A new comprehensive study across the Denver Health integrated health network yielded findings sure to come as surprise to both clinicians and policymakers alike.

“Most patients who return to the hospital frequently do so for short periods of time. The patients who were hospitalized multiple times last year tend not to be the same people who will be hospitalized frequently this year,” Dr. Tracy Johnson, director of health care reform at Denver Health told HCB News.

She is lead author of a just-published study on super-utilizers — patients with repeated hospitalizations, often dubbed “frequent flyers” by hospital staff — in the August issue of Health Affairs.

Johnson said there is a lot of good intent around developing primary care services to keep chronic users out of the hospital, but gaps in the existing literature on the topic prompted the study.

According to Johnson, it’s difficult to devise good health care policy to get super-utilizers into primary care medical homes if misunderstandings persist about the needs, both medical and social, of such patients. Population health strategies, like medical homes, are integral to the ACA's health reform objectives.

The study of nearly 5,000 publicly insured and uninsured adults with a history of repeated hospitalizations from mid-2011 through mid-2013 found that just three percent of patients account for 30 percent of charges in any given month. But nearly 75 percent of such patients dropped out of the super-utilizer category after 12 months. That number declined further to 86 percent after two years.

The needs of these patients tended to be short lived and caused by a cascade of events linked to chronic conditions, unmet behavioral health needs, and social issues. Johnson said that their study was consistent with prior research that has observed that many super-utilizers have multiple chronic conditions. However, medical complexity alone does not explain why these patients end up repeatedly hospitalized.

Examples of such patients include stroke or schizophrenic patients discharged from the hospital without a support network to assist at home. Such patients need help with basic functions (dressing, bathing, eating), getting medications and travel to doctors’ appointments. Of course, it's worth noting that some super-utilizers do not fit this profile at all — such as those receiving inpatient chemotherapy or those recovering from traumatic injury or orthopedic complications.

The study did confirm that super-utilizers are expensive for the health care system. Costs associated with such patients averaged around $114,000 at the peak of their frequent ER (gateway to a hospital) and hospital use, and dropped to less than $50,000 after the second year as their hospital use tapered off. The study was part of a $20 million grant to Denver Health from CMS, to design better primary care delivery for the large safety net population the system serves.

“The study clearly indicates that there is no one-size-fits-all solution to reduce avoidable hospital utilization,” Johnson said. “There are a lot of subgroups in this population and their needs are different.”

She said that Denver Health is already deploying solutions based on the research. For example, the data helped make the decision to open an Intensive Outpatient Clinic to help complex, chronically ill patients with medical, mental health, substance abuse and case management services.

Key features of this primary care clinic include real-time patient identification, outreach to patients while still hospitalized, and embedded social and behavioral health support. This keeps patients out of the hospital and in an outpatient setting that improves health and reduces costs.