Work lean, build community relationships

Working with super-utilizers doesn’t require a large team or a sophisticated infrastructure. It begins with identifying individuals in the community who have been frequently hospitalized within the last few months.

We recommend using lean start-up principles. A business methodology that favors experimentation, customer-centric design and continuous iteration.Before making major investments in staff or infrastructure, start learning more about the barriers to care in your community by finding and enrolling a few patients. Our patients are our best teachers.

Local social workers, physicians, discharge planners, nurses, and other care professionals are likely to know the super-utilizers in the community very well and are great resources for finding and connecting with these patients – ideally while the patients are still in the hospital.

Approach with respect and listen

Our enrollment specialists work in plain clothes—no scrubs, no lab coat, and no notebook. By working in plain clothes, they differentiate themselves from hospital staff.

Asking permission to pull up a chair and sit with a patient is respectful and helps to earn trust. Asking open-ended questions about a patient’s health and life helps to build rapport. The patient’s story is important, and listening is a powerful tool.

Gain their consent

Patients should be provided with a clear and accurate idea of how enrollment in an intervention may help them. We’ve learned that the critical question to ask is: do you want help staying out of the hospital? Once a patient agrees, they may be ready to sign a consent form to enroll in an intervention.