Case study shows program’s success

When members of the multidisciplinary High Utilizers Group (HUG) team at Lehigh Valley Health System in Allentown, PA, began analyzing the case of the individual who topped the list of high utilizers, they realized that everybody on the team had worked with him in one capacity or another.

The patient had been in and out of the hospital frequently and had made multiple visits to the emergency department. “When we looked at everything that was going on with this patient, we determined that he had experienced multiple losses. His mother died, he was going through a divorce, and he had lost his job,” says Maureen Sawyer, MSW, LSW, ACM, director of case management for the three-hospital system.

Multiple people had tried to reach out to him and engage him in following his treatment plan but had been unsuccessful. “Nobody had been able to develop a close relationship. When he came to the emergency department, he was treated by a different person every time. He didn’t always have the same caregivers on the inpatient unit,” Sawyer says.

A home health nurse on the team who was trained in behavioral health and crisis intervention had worked with the patient in the past and had a mostly positive relationship. The nurse started visiting the patient when he came into the emergency department and on the inpatient unit and following up at home. In the beginning, the patient didn’t answer the telephone or the doorbell, but the nurse finally was able to gain his trust and get him to participate in therapy in the home setting. The patient’s visits to the emergency department and hospitalizations are less frequent now.