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Greater Boston Super-Utilizer Project |
Massachusetts |
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The Greater Boston Super-Utilizer Project connects patients who are high-utilizers of Beth Israel Deaconess Medical Center's Emergency Department to a multidisciplinary outreach team from the Brookline Community Mental Health Center. The outreach team specializes in behavioral health issues like addiction and mental health, both common challenges for super-utilizers. The program is based on the Program of Assertive Community Treatment (PACT) model which uses team-based treatment that is focused on enabling patients to live independently in their communities to the fullest extent possible. This involves a high-touch approach with frequent, multiple contacts between the care team and patient as well as clear coordination and communication between hospital staff and the care team. |
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Partner Organizations |
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Target Population |
Ultra-utilizers (defined as patients with 7-25 hospitalizations in the past year) living within a 2 mile radius of Beth Israel Deaconess Medical Center who have 2 or more chronic medical conditions plus persistent mental illness |
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Care Team |
Nurse practitioners, nurse, community outreach worker, supervised by a psychiatrist and a program manager (psychologist) |
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Timeframe |
2013 - present |
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Results/ Studies |
N/A |
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Funding |
Private grant |
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Resources |
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