Health Hot-spotting: Utilizing Novel Alternative Intervention and Data to Create Better Outcomes for Super-Utilizers and Underserved Populations

Tammy Hawley


As little as five percent of a community can take up more than half the total health expenditures. This ratio is, in part, due to the excessive use of the emergency department for medical issues that could instead be addressed through primary care. To better understand why people over-utilize the emergency department, it is necessary to merge patient service utilization data and create an alternative intervention plan that addresses a biopsychosocial model of health. This shows a larger picture of what is going on in patients’ lives that one cannot gather in a typical office visit. In addition to being more cost-effective, this union of data and human connection may lead to more effective treatment and wellbeing in patients who are currently underserved or obtain poor outcomes. Such an alternative is currently in practice. It is known as Bridges to Health and is comprised of an interdisciplinary team consisting of a behavioral health specialist, a primary care provider, and a case manager. Data will be collected through chart reviews for patients enrolled in the Bridges to Health Program at the Henderson Family Health Center, and in The Free Clinics of Hendersonville, North Carolina. Analysis of the data for possible correlations, monetary implications, and utilization effectiveness will then be performed. Future research will attempt to explore novel methods for quantifying the impact of such programs on patients’ emotional well-being and overall health.


Super-Utilizers, Cost Effectiveness, DIGMA, Health Hot-spotting

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