Innovative Care Management Program Continues to Transform the Lives of Super Users While Saving Millions

Article Summary

The Queen’s Care Coalition, an innovative care management program developed by The Queen’s Health System (QHS) to better support its patients who are homeless and frequently utilize emergency department (ED) services, has positively impacted patients and reduced costs. However, the COVID-19 pandemic created challenges requiring the need to change the delivery of its services and decrease face-to-face interactions during the height of the pandemic while also addressing the organization’s capacity constraints. This shift helped the organization continue to provide necessary care and support to marginalized patients while reducing utilization and costs.


innovative care management
Featured Outcomes
  • $7.1M cost savings.


Nationwide, patients who are homeless visit the ED at a rate 4.8 times higher than patients who are non-homeless.1 The COVID-19 pandemic exacerbated long-standing inequities and social processes contributing to health disparities, with COVID-19 affecting the most vulnerable.2 In Hawai’i during the pandemic, the state went from having the lowest unemployment rate of all 50 states to having one of the highest unemployment rates.3 As a result, chronic homelessness in Hawai’i increased by 18 percent after the pandemic.4 QHS needed to shift its innovative care management delivery method to continue to support this vulnerable population.


QHS developed the Queen’s Care Coalition, an innovative care management program, to address the needs of super-utilizers—patients with 15 or more ED visits in a quarter, three admissions to Queen’s Medical Center in a quarter, or 15 days of hospitalizations in a quarter. The organization improved the care provided to these patients and reduced costs by more than $16 million.

However, the COVID-19 pandemic further exacerbated many of the challenges faced by these patients, and QHS faced capacity constraints. The same patients continued to access the ED for nonemergency care and services, and difficulties with post-discharge placement led to prolonged length of stay (LOS) for some patients. QHS needed to change the delivery of its services to decrease face-to-face interactions during the height of the pandemic and effectively manage limited ED and inpatient capacity while still providing the individualized, supportive care its patients needed.


During the pandemic, Queen’s Care Coalition patient care navigators shifted their patient care contact to telephonic delivery. The organization provided mobile phones for patients enrolled in the care management program, ensuring they could maintain contact with their patient care navigator. These navigators helped Care Coalition patients transition to virtual visits, supporting and coaching patients in using new technology for their medical appointments.

Navigators focus on comprehensive care

Navigators maintained their focus on ED super-utilizers and continued to provide services to patients for 90 days. When patients present to the ED for services, navigators provide the care team with a comprehensive patient history, collaborating with care teams to develop a comprehensive plan for expediting treatment and realistic treatment plans. Navigators also shifted their focus to help address inpatient capacity, providing greater support, discharge planning, and coordination for patients with prolonged LOS.

With this system, navigators help develop the discharge plan and closely follow up with patients post-discharge to help prevent unnecessary readmission. Navigators collaborate with community housing partners, assisting patients in finding a safe location post-discharge. In addition, navigators may help patients experiencing homelessness secure housing at a shelter, senior housing facility, or permanent housing.

Navigators use a harm-reduction approach

Queen’s Care Coalition navigators continue to use a harm-reduction approach, meeting patients where they are. That means physically—meeting at homes, on streets, or in parks, wherever the patient may be—and mentally—meeting individual patients where they are in relation to their goals and priorities.

Navigators work with patients and dozens of community agencies and partners to address each patient’s priorities and work with them to reduce the negative consequences associated with homelessness and high-risk health behaviors, including exploring personal beliefs that impact full participation in medical care and taking medications as prescribed. Navigators develop supportive, positive relationships with patients, adjusting the services and support to meet the needs of the patients. They accompany patients to medical appointments and interviews for benefits like the Supplemental Nutrition Assistance Program. Even more, navigators arrange transportation to appointments, help patients with skills training, increase their ability to manage activities of daily living and independent living skills, and provide culturally competent care that helps reduce disparities and decrease mistrust in the medical system.

Navigators use data and analytics to make informed decisions

QHS continues to leverage the Health Catalyst® Data Operating System (DOS™) platform for data and analytics, including documentation of housing status data into the Instant Data Entry Application (IDEA) for Queen’s Care Coalition patients, ensuring the data are readily available for analysis and reporting in DOS. Navigators document patient outreach activities in the EMR. QHS uses payer, patient, and patient flow data for ongoing program evaluation and data-informed decisions.


After successfully transforming the lives of its patients and eliminating more than $16M in costs, the Queen’s Care Coalition effectively navigated the COVID-19 pandemic, providing care and support to marginalized patients while reducing utilization and costs. QHS observed:

  • $7.1M cost savings. Patients spent >2K more days at home, the result of a 76.1 percent relative reduction in inpatient days.
    • 71.6 percent relative reduction in inpatient admissions.
    • 15.9 percent relative reduction in LOS.
    • 37.1 percent relative reduction in 30-day readmissions.

Perhaps more important is the positive impact navigators have on the lives of the patients they support. Hundreds of patients have been supported by the Queen’s Care Coalition. As a result, people who have experienced homelessness for years have received shelter. Individuals who never learned how to cook now know how to prepare themselves a meal. Even after patients have been discharged from the program, their navigator is still the first person they call when they have a problem—a testament to the navigator’s valuable impact on their lives.

“The Queen’s Care Coalition team consistently puts our patients and their needs at the center of our work. Our teams always remember that the patient and their needs are what is the most important.”

Tiffany Mukai, LCSW, Manager, Queen’s Care Coalition, The Queen’s Medical Center


The Queen’s Care Coalition will continue to connect patients with high needs and high costs to services in the community, providing the right care in the right place, avoiding unnecessary ED and inpatient utilization, and transforming the lives of the patients it serves.


  1. QuickStats: Rate of Emergency Department (ED) Visits, by Homeless Status and Geographic Region — National Hospital Ambulatory Medical Care Survey, United States, 2015–2018. MMWR Morb Mortal Wkly Rep 2020;69:1931. Retrieved from
  2. McGrail, K., et al. (2022). Looking back and moving forward: Addressing health inequities after COVID-19. The Lancet Regional Health – Americas. Retrieved from
  3. Liou, W. et al. (2021). Hawaii’s labor market impact during COVID-19. State of Hawaii – Department of Business, Economic Development, & Tourism. Retrieved from
  4. 2022 Point in Time Count. (2022). Hawai’i Health Data Warehouse. Retrieved from


Improving Atrial Fibrillation Management Decreases the Risk of Stroke

This website stores data such as cookies to enable essential site functionality, as well as marketing, personalization, and analytics. By remaining on this website you indicate your consent. For more information please visit our Privacy Policy.