Frequent Users of Health Services Initiative

Across California, many hospital emergency departments are treating individuals who visit hospitals multiple times a year, often because of complex physical, mental, and social needs. Known as “frequent users,” these individuals often experience chronic illness, mental health, and substance abuse disorders, and homelessness.

Launched in 2002, the Frequent Users of Health Services Initiative was a six-year joint project of The California Endowment and the California HealthCare Foundation, with program direction and technical assistance provided by the Corporation for Supportive Housing. The Initiative included six pilot programs designed to test new models of care for “frequent users” of hospital emergency departments.  Through grant making and intensive programming, the Initiative focused on building a more responsive system of care to decrease frequent users’ avoidable emergency department visits and hospital stays.

Two-thirds of frequent users have untreated physical conditions: diabetes, cardiovascular disease, cirrhosis, respiratory conditions, seizures, hepatitis C, HIV, and chronic pain.

  • 58% suffer substance abuse disorder
  • One in three has a mental illness
  • Half are homeless
  • 36% have three or more of these conditions

These patients face barriers in accessing housing and medical, mental, and substance abuse treatment, all of which can contribute to frequent emergency department visits. Emergency departments are a community resource and are the only health care resource that by law must serve everyone. They also provide the most expensive health services in our communities. Frequent users’ hospital visits can account for disproportionate costs and time for emergency departments, contribute to emergency department overcrowding, and drain state and county health care resources.

Frequent users average:

  • 8.9 ED visits each annually, with average annual charges of $13,000 per patient
  • 1.3 hospital admissions annually
  • 5.8 inpatient days each, with average annual charges of $45,000 per patient

Key Strategies
The Initiative has developed and implemented five major strategies to ensure that the healthcare needs of frequent users are met through more rational and effective models of care:

  • Grant-Making and Monitoring to provide critical elements needed to develop, implement, and test new  models of care and related support services.
  • Policy and System Change to improve systems of care and promote cost-efficient alternatives to high-cost  emergency department visits.
  • Communication and Dissemination to provide information to broad local, state, and national audiences on the best practices developed by the Initiative programs.
  • Technical Assistance and Capacity Building to influence sustainable changes in health care delivery.
  • Evaluation, which includes both system-focused and individual-focused outcomes.

Impact and Outcomes

Promising Models of Care
The Initiative was designed to develop new models to better serve frequent users, replacing a costly and ineffective cycle with ongoing, coordinated, and multi-disciplinary care provided in more appropriate settings.

At the heart of the Initiative are the demonstration projects that test new models of care for frequent users throughout California. The Initiative funded six three-year implementation grants – one awarded in 2003 and renewed for an additional year in 2006, and five awarded in the second, and last, round of funding in 2004. The pilot programs were located in the following counties:

  • Alameda County – Project RESPECT
  • Los Angeles County – Project Improving Access to Care
  • Sacramento County – The Care Connection
  • Santa Clara County – New Directions
  • Santa Cruz County – Project Connect
  • Tulare County – The Bridge

Through these pilot programs, local hospitals and service providers collaborated in the development and implementation of more responsive systems of care to:

  • Address frequent users’ unmet needs
  • Produce better outcomes
  • Better use emergency department resources

Early results from the Initiative programs have shown that a multi-disciplinary, coordinated care approach can reduce emergency department visits and costs, while improving the stability and quality of life for patients.


The Initiative is supported by the California Endowment and the California HealthCare Foundation. Both foundations provide oversight to the Initiative Program Office.

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