1. Valente, Jessica MD, MPH
  2. Bundy, Richa MPH
  3. Martin, Melanie MD
  4. Palakshappa, Deepak MD
  5. Dharod, Ajay MD, FACP
  6. Rominger, Robert PhD
  7. Feiereisel, Kirsten MD


With rising health care costs, health systems have adopted alternative care models targeting high-need, high-cost patients to improve chronic disease management and population health. Intensive primary care teams may reduce health care utilization by tackling medical and psychosocial needs specific to this patient population. This study presents health care utilization trends from a high-intensity primary care program that employs a multidisciplinary team (including clinicians, psychologists, pharmacists, chaplaincy, and community health workers) and community partnerships. Using descriptive statistics and Poisson rates of differences, this study evaluates patient and utilization characteristics of those enrolled (n = 341) versus declined (n = 54) program participation from 2013 to 2020. Both enrolled and declined patients experienced significant reduction in emergency department and inpatient utilization, but differences between enrolled and declined patients were not statistically significant. Programs aimed at decreasing health care utilization for high-need, high-cost, medically complex patients may be best supported by interventions that simultaneously address social and behavioral health needs.