The Alameda Health System (AHS) High Utilizer Team (HUT) pilot program at Highland Hospital (HGH) is an example of what can happen when AHS providers and staff across multiple disciplines collaborate to ensure AHS patients are getting the right care, at the right time, in the right place.

In December 2020, a High Utilizer workgroup was created to better understand and help people with a pattern of frequent utilization of the HGH Emergency Department (ED) and eliminate the use of the ED for non-emergent care. The workgroup is led by Lilly MacRae, RN, manager of outpatient services and complex care transitions, along with Isha Jethi, supervisor in complex care.

Pictured left to right: Jimmie Gamble, AHS patient and Tashiana Colston, AHS clinical social worker

In addition, Tashiana Colston, clinical social worker, Saundra Mercado, community health outreach worker and Fiona Thomson, nurse care manager joined HUT to help find solutions for better patient care and services.

“It was clear there was a significant gap in care coordination and case management for patients who come to the ED and are admitted on a weekly or monthly basis,” said MacRae.  “Our collective goal is to follow people with a pattern of frequent utilization of the ED and hospital to understand the barriers they face and build system strategies to meet their needs,” she shared.

Oakland native Jimmie Gamble is one of HUT’s earliest success stories. He was frequently utilizing the HGH ED to obtain life-saving hemodialysis treatment for his end-stage kidney disease. Colston and Thomson began having weekly meetings with Gamble to better understand the experiences and barriers he faced trying to obtain the appropriate care in the community.

They also held interdisciplinary case conferences with AHS providers and staff to create a plan to meet Gamble’s immediate medical needs including the ability to obtain home peritoneal dialysis.  The team reached outside to a local nephrologist for support in helping Gamble find the right place for treatment.

“Gamble knew the ED was not the right place to obtain his weekly treatments, but he had no other option, and he was doing the best he could to find the right place to meet his needs,” said Colston.

According to Gamble, who was diagnosed with end-stage renal disease (ESRD) in 2019, a physician at a different health care organization instructed him to go to the HGH ED for dialysis where he would become frustrated due to the long wait times and lack of access to certain treatments.

Colston also discovered he had been trying to find dialysis care at several medical facilities across the Bay Area with little success. “It was clear, Mr. ‘G’, as he likes to be called, kept running into barriers including quick access to care and communication issues,” she said. “He didn’t feel heard or understood.”

Colston shared that unfortunately patients like Mr. G who advocate for their own health and wellness, are often mistakenly labeled as a ‘problem’ in health care settings. “Many patients of color often face challenges when engaging with health care professionals and are not taken seriously.” said Colston. “Patients like Mr. G want to feel validated and acknowledged during medical visits.”

With the collaboration and support of HUT and ED physicians, Gamble was referred to the Davita Kidney Care center in Walnut Creek for regular dialysis treatments. “The quality of my life immediately changed,” said Gamble who received training and a portable dialysis machine from Davita. “I am now able to take my treatments at home and no longer have to visit the ED several times a week. It gives me more freedom and flexibility.”  In addition, he shared that at-home dialysis puts him in control of managing his kidney health which eliminates his previous stress and worry.

Gamble refers to the members of HUT as family. “This is the first time since I was diagnosed with kidney disease in 2019 that I felt that anyone in health care truly cared, listened and wanted to help me,” said Gamble.

Since its inception the HUT pilot program continues to grow and currently includes twenty patients. MacRae shared that the goal remains the same which is to provide patients with the care and support they need by reducing their reliance on the ED for all non-urgent health care services.

“What makes this work so special is that our team always holds the patient at the center of everything we do which guides us toward the best solutions and health care outcomes for all,” said MacRae.

Gamble shared his time with HUT changed his outlook on the health care experience for people of color. “This team is the gold standard for how all people should be treated regardless of their race, ethnicity or background,” he said. “I don’t know where I would be without them today.”

To learn more about implicit bias and racial inequities in health care visit the Health Equity, Diversity & Inclusion Resources Page (internal).