Community Connection: Transforming Care

Community Connection: Transforming Care for High Utilizers of the Emergency Room

A segment of patients with complex health conditions end up being “high utilizers” of emergency departments (ED). This often leads to fragmented care and drives rising health care costs. This webinar shows how you can leverage the patient-centered medical home (PCMH) model to identify those high utilizers – especially those with mental illnesses and substance use disorders – and connect them with social and behavioral health services that can help them avoid excessive ED use.

It will also explain how to better integrate these patients into primary care. The session will include interactive dialogue and leverage real life lessons learned from a program the University of Vermont Health Network used to better manage these patients.


University of Vermont Health Network-Champlain Valley Physicians’ Hospital, which serves a rural population, discovered that a disproportionate number of patients were using the local hospital’s ER for reasons other than emergency care. The plan learned that many of these patients lacked access to primary and mental health care, due in part to the limited number of available health care professionals in the area. Patients had trouble accessing primary care and frequently had to navigate the health care system on their own—which led to high rates of hospitalizations, readmissions and noncompliance with discharge plans. And they faced other challenges: low health literacy, lack of support for behavioral health and substance use issues, unemployment and low socioeconomic status.

In response to this issue, University of Vermont Health Network developed a “high utilizer” program designed to connect high utilizers with social and behavioral health services and with primary care. As part of this program, the hospital care team recruited multidisciplinary representatives from community organizations. Care managers in primary care practices helped identify care teams and coordinate patient services—resulting in successful outcomes.


The high utilizer program was designed to connect community partners to high utilizers with social and behavioral health services that were not readily available. The program also helped make the connection with the primary care providers. Therefore, the hospital team emphasized the need to include multidisciplinary representatives from community organizations to strengthen partnerships and provide patients with social and behavioral health services. The Care Managers within the primary care practices helped identify the care team and coordinate the services with the patient, allowing for successful outcomes.


  1. Increased communication with the community based organizations to assist with coordinating the high utilizers care needs, creating and implementing patient centric care plans, realizing that more than clinical services are required to assist these patients. This collaboration required weekly meetings.
  2. Increased awareness of the ER staff of the unique needs of the high utilizers, realizing persistence is key, that progress is slow and labor intensive.
  3. Peer support in assisting with these patients to connect with the community resources was vital to the success of the program.

Learning Objectives

At the conclusion of the module, participants will have the knowledge they need to:

  1. Identify actions necessary to create a patient-centric approach to care.
  2. Implement standards for a successful, effective referral process with community partners.
  3. Recognize the value of the community team in supporting and guiding patients in successful self-management.
  4. Describe the steps toward creating trust and resolving issues with high-needs populations.
Course summary
Available credit: 
  • 1.00 Participation
  • 2.00 PCMH CCE
Course opens: 
Course expires: 

Brenda Stiles

Brenda Stiles is the Director of Care Management and Quality of the Adirondacks ACO. She leads the Care Management Services provided by a robust team of nurses, community resource advocates, nutrition educators, patient navigators, a pharmacist and support staff. The care team supports the primary care providers within the network using evidenced based care guidelines to optimize the health of the provider’s panel of patients. The ability of the team to design a patient centered approach to the patient’s care addressing both preventive and chronic illness needs, incorporating patient goals, barriers and values is critical to achieve optimal outcomes for the patient, leading to successful self- management. High-risk patients are identified to determine they are receiving appropriate care management services. A strong focus on transitions of care across the care continuum ensuring successful outcomes focuses on: medication management and reconciliation; plan for transition; patient/family education; information transfer; follow up care; health care provider engagement; and shared accountability amongst the care team providers.

Ms. Stiles has a Bachelor’s Degree in Nursing from SUNY Plattsburgh. She has more than 30 years of nursing experience ranging from college nursing, home care and assisted living administration. She is a Certified Diabetes Educator and a PCMH CCE

As a PCMH CCE Program update, this webinar provides "Other CCE Continuing Education" maintenance of certification credit (2 points).

This is a non CME/CNE/CPE activity.

Available Credit

  • 1.00 Participation
  • 2.00 PCMH CCE


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