Introduction: Super-utilization (frequent acute hospital care use or frequent emergency department (ED) utilization and readmissions) describes high rates of emergency department visits and hospital admissions by some individuals. A large empirical literature which has not shown significant improvements over the past 12 years. Reducing healthcare costs per capita have focussed on Super-utilization, system transformation, and care management. The complex dynamics systems driving Super-utilization lack prominence. Aims: The review aims to uncover essential frameworks and articles to interrogate the mindset of Super-utilization and its evolution to illuminate current understandings and prevailing themes. Methods: Utilizing primary articles, search terms were refined iteratively for searches on Super-utilization, Super-utilizer, and Care Management themes. Articles were intentionally chosen to illustrate primary themes. The review included the most recent and relevant articles to provide a narrative of the diverse set of taxonomies related to Super-utilization Findings: Common to all 4 searches were utilization outcome measures. Care Management was the second common theme. Needs were the lowest frequency in Super-utilization 8% compared with Superutilizers 20% and Care Management 24-25% searches. Systematic reviews and key studies demonstrated limited success of care management, including system transformation from health into social care. Centralised policies such as the Triple Aim have inherent polarities. Health services must contain costs and meet felt needs that emerge from under resourced personal journeys and underserved communities. Conclusion: Super-utilization is an expanding concern within academic literature. Efforts to reduce frequent and multi-dimensional acute care presentations using current care models appear ineffective. The predominant focus on utilization and costs, wedded to a care management model, has diverted attention from taking both a more needs-centred and a broader complex systems perspective on Super-utilization. Distributive justice asks whether social funding should be increased in preference to expanding current health spending.

The Universal Health (UHC) movement in its latest iteration, has adopted key objectives of Primary Health Care (PHC). This is a notable shift in the right direction but achieving what appears to be simple targets is a highly complex endeavour across both wealthy and less wealthy countries and jurisdictions. Improving health for all targets requires political-economic, bureaucratic and alignment with bottom-up grass-roots agencies. Despite present successes, there is a need to adapt to constant challenges including pandemics, adverse climate phenomena and political-economic shifts.

Rationale aims and objectives Potentially preventable hospitalizations (PPH) are a challenge. What happens before hospital admission? Are there crucial tipping points before admissions in at-risk cohorts’ trajectories? HealthLinksChronicCare (HLCC) hospital risk-prediction algorithms using admission, diagnosis, and lifestyle data identifies at-patients. MW monitors HLCC patients with outbound phone calls using telehealth – the Patient Journey Record System with alerts representing a real-time anticipated risk of PPH. Health Coaches triage and intervene to optimize GP, hospital and community service utilization to reduce the risk of PPH. Aims To describe a time series of telehealth phone calls related to an acute admission ( 10 days) to investigate tipping points in self-reported biopsychosocial environmental concerns (total alerts) and or condition symptoms of concern (red alerts). Methods MW participants had an acute (non-surgical) admission and >44 calls between 23/12/16 - 11/10/17. The Patient Journey Record System (PaJR) and Victorian Admitted Episode Data/ Emergency Minimum Dataset provided longitudinal data. Descriptive time series analysis employed Pettitt’s homogeneity test to detect ‘tipping points’ using XLSTAT package. Findings One hundred three patients aged 74 ± 15.4 years, with 59% male and 61% female, provided 764 call records around admission(s) and 22,715 records over 10 months. Total alerts and red alerts were higher in the 10 days before and after admission. Total alerts significantly increased (tipped) at day 3 before hospitalisation persisting until 10 days. Red alerts increased (tipped) 1 day before admission and remained high following discharge. Discussion and Conclusion Self-report in phone calls describe a pre-hospital phase of ‘post-hospital syndrome’ (PHS), which began at least 10 days before admission and persisted after discharge. Wide-ranging health, psychosocial, and environmental concerns preceded a tipping point into acute symptoms. Telehealth monitoring of biopsychosocial, as well as disease, concerns require further investigation.

Rationale, aims and objectives. Applying traditional industrial Quality Improvement (QI) methodologies to primary care is often inappropriate because primary care is best thought of as a network of highly interconnected agents in a complex adaptive system (CAS) that is particularly responsive to bottom-up rather than top-down management approaches. We report on a demonstration case study of improvements made in the Family Health Center (FHC) of the JPS Health Network in a refugee patient population that illustrate features of QI in a CAS framework as opposed to a traditional QI approach. Methods. We report on changes in health system utilization by new refugee patients of the FHC from 2016-2017 and summarize relevant theoretical understandings of quality management in complex adaptive systems. Results. Applying CAS principles in the FHC, utilization of the Emergency Department and Urgent Care by newly arrived refugee patients before their first clinic visit was reduced by more than half (total visits decreased from 31% to 14% of the refugee patients). Our review of the literature demonstrates that traditional top-down QI processes are most often unsuccessful in improving even a few single-disease metrics, and increases clinician burnout and penalizes clinicians who care for vulnerable patients. Improvement in a CAS occurs when front-line clinicians identify care gaps and are given the flexibility to learn and self-organize to enable new care processes to emerge, which are created from bottom-up leadership that utilize existing interdependencies made more sustainable as front-line clinicians use sensemaking to improve care processes. Conclusions and future directions. Recent reforms announced in primary care in Scotland, a few examples in the medical literature, and statements from some healthcare system leaders are examples of early adapters who are applying the principles of CAS to their QI efforts. Such initiatives and our example provide models for others to follow.