An intensive primary care program for super-utilizer patients-a mixed-methods study.

Abstract (English)

BACKGROUND: We report on an intensive primary care (IPC) program at the JPS Health Network (JPS) in Tarrant County, Texas, for super-utilizer patients. METHODS: The IPC team consisted primarily of a family physician and community health worker. From 2019 to 2022, the physician approached super-utilizer patients, defined as 4+ emergency department (ED) visits or 2+ inpatient visits in the previous six months, offering to provide 24/7 personal care. The main outcomes wereED visits and hospitalizations one year before/after the index visit. For the qualitative component, 10 patients of the IPC program and 4 members of the IPC care team were interviewed. Thematic analysis provided insight into patterns of meaning-making and understanding participants' perspectives. RESULTS: One hundred and forty-three patients were seen by the IPC physician, 128 with 2+ encounters (IPC patients), and 15 with one encounter. The IPC patients had 12 ED visits per-person year in the preperiod and 9.6 in the postperiod (-20%); compared to the one encounter control group with 13 per-person year in the preperiod and 15.5 in the postperiod (+23%). Three themes were developed. The IPC team: (1) mitigated the effects of various social determinants of health; (2) rebuilt trust with the health system; and (3) provided flexible medication access, benefits, and minimized specialty referrals, hence minimizing challenges accessing care to improve navigation of the health systems. CONCLUSIONS: The JPS IPC program likely reduced ED use through addressing social determinant challenges, rebuilding trust with the healthcare system, and establishing a flexible comprehensive primary care relationship, demonstrating the potential of IPC models.