Building Capacity to Help ‘Superutilizers’ in Underserved Communities

By the time Mark reached his early 40s, years of alcohol abuse had almost killed him. On the day he first met with Chris Ruge, a nurse practitioner in New Mexico, Mark was incoherent, with 20 pounds of fluid in his abdomen a clear sign that his liver had nearly stopped working. Ruge called 911, and Mark spent four weeks recovering in an ICU and skilled nursing facility. He was unable to walk and barely able to talk when he was discharged, but started drinking again within days.

Ruge and his care team are throwing lifelines to Medicaid beneficiaries like Mark—the “superutilizers” who accrue very high health care costs because of their addictions, mental illness, and physical health problems, which are often compounded by poverty and social isolation. To help Mark, Ruge spent hours with him. “We didn’t talk about medical stuff,” he says. “I just talked to him about his life and asked whether he wanted to stick around.” After several such conversations, Mark told Ruge he was ready to get sober, and asked for help.

Ruge and his colleagues are guided in this work by experts at the University of New Mexico’s Project ECHO (Extension for Community Health Outcomes) program, which for more than a decade has been using telehealth to support primary care clinicians caring for complex patients in underserved communities. In Project ECHO’s latest effort, the experts are training five primary care teams in the field via regular videoconferences to offer therapy and medication to treat patients’ mental illnesses and addictions, provide hands-on support in managing their physical health problems, and connect them with housing and other social supports to stabilize their lives.