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

We report on an intensive primary care (IPC) program at the JPS Health Network (JPS) in Tarrant County, Texas, for super-utilizer patients.

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.

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.

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.