Accelerating Best Practices in Peer Support Around the World

Peer Support and High Utilizers of Care: Addressing Social and Medical Needs Through a Care Management Program

Laura Guzman-Corrales, MPH Candidate

In the United States, 10% of individuals account for 65% of health care spending in a given year (Kaiser Family Foundation, 2012). Many of these high utilizers are patients with multiple co-occurring conditions and unmet social needs. The Camden Coalition of Healthcare Providers (CCHP) has developed an innovative approach to identify and improve the health of these individuals. This blog introduces the idea of “hot spotting” and describes an intensive care management program designed for high utilizers featuring several components of peer support.

Hot Spotting: Using Data to Find High Need Patients

The CCHP began collecting public and private insurance claims data in 2002 (Robert Wood Johnson Foundation, 2012). This data allowed them to identify “hotspots” where the highest utilizers of health care services were geographically located. CCHP narrowed down the highest utilizers to two apartment complexes in the city—one housing mostly poor, elderly, and disabled residents and the second providing acute rehab and nursing home services. In aggregate, these two buildings accounted for $27 million in health care expenses over five years (Brenner, 2013).

In addition to being poor and elderly, high utilizers face numerous challenges when it comes to addressing their health needs and interacting with the healthcare system. According to a qualitative study conducted with patients receiving intensive services, many CCHP patients had a history of childhood instability and trauma, experiencing early deaths of parents or other caregivers, histories of sexual and physical abuse, homelessness, gang involvement, and early drug use (Mautner, 2013). Past trauma contributed to chronic physical and mental health problems well into adulthood.

Patients also often reported complicated histories with providers and the health care system. Many described incidents of racial and gender-based discrimination and disrespectful attitudes conveyed by providers (Mautner, 2013). These negative interactions led to distrust and disengagement with medical services. Almost half of participants in the previously mentioned study described distrusting at least one specific provider that they saw regularly and skipping scheduled appointments as a result (Mautner, 2013). 

Addressing Social Needs through Care Management Teams

Past interventions have been ineffective at helping patients with complex health problems, partly because they neglected to address patients’ social needs and the ways these needs influence their interactions with the healthcare system. CCHP designed a care management program using hot spotting data to target high utilizers of care with a comprehensive set of services (Robert Wood Johnson Foundation, 2012). The CCHP Care Management Team, which includes nurses, social workers, health coaches, and Americorps volunteers, performs regular home visits where they provide intensive services to patients. Some of the services include going to appointments with patients, helping complete paperwork, filling prescriptions, and navigating different social service resources in the community (Brenner, 2013).

Several factors that contributed to the program’s success are reminiscent of the core functions of peer support. First, the Care Management Team is expected to provide emotional support to patients. In a qualitative study, most patients identified “feeling cared for” as their favorite part of the intervention (Mautner, 2013). Patients felt like the care teams showed them love and respect and treated them like individuals, not statistics.

Second, the intervention emphasized linkage to health care and community resources. The CCHP intervention recognizes that social needs can outweigh medical needs for certain patients (Robert Wood Johnson Foundation, 2012). Many high-utilizers experience housing instability, extreme poverty, and other social deficits that exacerbate mental and physical health conditions. By coordinating care among social workers, health coaches, and Americorps volunteers, teams are better able to link patients to community resources that can help address their social needs, as well as their medical needs.

Third, the intervention was effective at improving provider-patient relationships through collaborative care. While past negative interactions with providers led to disengagement with medical services, positive interactions improved patients’ perceptions of the health care system and their provider. As a result of interactions with their care team, patients were more receptive to the information they received from their providers at appointments (Mautner, 2013).

While results of the intervention are limited, a study of 36 patients found that monthly costs of treating these patients dropped 56% and monthly hospital visits dropped 40% (Green, Singh, & O’Byrne, 2009). While these findings reflect a small sample, they demonstrate the possible positive effects of a targeted care management intervention.

Future Considerations for Dissemination

The CCHP Care Management Team provided outreach to 312 people between 2007 and 2010 (Green, Singh & O’Byrne, 2009). As of June 2010, they were actively managing 108 patients, many of who required biweekly home visits. Many more patients could benefit from care management services, but disseminating a resource intensive program of this nature presents a number of challenges. One challenge is collecting the data to identify the hotspots. Insurance claims information must be collected regularly in order to be most effective and can present a challenge to organizations that lack the technical capacity to collect and analyze this type of data.

Another challenge is finding the right staff to continue to grow the program. Because providing emotional support is one of the cornerstones of the intervention, it is important to choose members of the care team that can provide emotional support and caring to high need patients. Not all service providers can work intensively with complex patients. Peer supporters, however, are often chosen for programs because of their familiarity with community services and their interpersonal and communication skills. Using more peer supporters may be one key to expanding the reach of the program, given the success in using health coaches.

The CCHP has shown us how data can inform targeted interventions for hard to reach populations. The Care Management Team re-engages patients that have become disillusioned with the healthcare system and helps them address their health needs by satisfying their social needs.


Kaiser Family Foundation. (2012). Health care costs: A primer.

Green, S.R., Singh, V., & O’Byrne, W. (2009). Hope for New Jersey’s City Hospitals: The Camden Initiative. Ne Jersey Department of Banking and Insurance Office for Electronic Health Information Technology.

Mautner, D. B., Pang, H., Brenner, J. C., Shea, J. A., Gross, K. S., Frasso, R., & Cannuscio, C. C. (2013). Generating Hypotheses About Care Needs of High Utilizers: Lessons from Patient Interviews. Population health management, 16(S1), S-26.

Robert Wood Johnson Foundation. (2012). Expanding “Hot Spotting” to new communities: What we’re learning about coordinating health care for high utilizers. Robert Wood Johnson Foundation: Washington, D.C.

Brenner, J.C. (2013). Jeffrey C Brenner on driving down the costs of care. Healthcare Financial Management, 67(1):72-75.


/ Leave a Comment /

Your email address will not be published. Required fields are marked *


e-Newsletter Signup
Thank you!

You have successfully subscribed to the Peers for Progress Newsletter.

To unsubscribe, click the unsubscribe link at the bottom of any e-Newsletter email.

Sorry, there was a problem.

We're sorry but there was a problem processesing your submission. Please try submitting again. If the problem persists, please contact us.

Please use this form to be added to the Peers for Progress e-Newsletter mailing list. Be the first to receive the latest news and resources on program development, state-of-the-art research, and networking opportunities.

Previous newsletters may be found at News & Events > Peers for Progress Newsletters.