By Enrique Enguidanos, MD, MBA

The High Utilizer of Virginia (HUV) program reduces duplication of efforts while improving the quality of care for enrolled members. Improved care collaboration and 24/7-member access to support provided by Community Based Coordination Solutions (CBCS) has been integral to this program’s success in reducing high-cost utilization and improving outcomes—especially for members with behavioral health diagnoses.

The Challenge

Vulnerable patient populations often struggle to navigate a healthcare system built for providers, not for patients. This is true even when case management services are provided. When patients are unsure of available options, they turn instead to high-cost acute care, fail to receive appropriate follow-up, and inevitably end up back in the hospital.

The result? At least $47 billion (1. Accenture, 2021) in unnecessary annual care costs from ED utilization as just 5% (2. Jared OrtalizaMatthew McGoughEmma Wager Gary Claxton, and Krutika Amin, Peterson KFF, November 2021) of the population accounts for half of all healthcare spending in the US.

For vulnerable patients with behavioral health conditions, the needs become even more complicated. Currently, an estimated 34 million, or 17%, of adults (3. Ken Thorpe, Sanjula Jain, and Peter Joski, January 2017) in the US live with comorbid chronic and behavioral health conditions. In high-cost, high-utilization populations, that percentage is higher at 40%. Creating appropriate programs to support these individuals often requires significant staff, time, and financial resources as well as a keen understanding of the populations served. Without these resources, patients revert back to the hospital as their default choice for receiving care.

At the Department of Behavioral Health and Developmental Services (DBHDS) in Richmond, Virginia, leadership was facing significant overcrowding of state psychiatric hospitals while also navigating staffing shortages across the board. As a result, DBHDS was actively looking for a better way to support their members with behavioral health conditions—especially in light of the Covid-19 pandemic. A majority of members were enrolled in Medicaid, and the urban area meant a solution was needed that could meet the varied needs of a racially diverse population.

Suzanne Mayo, Senior Director of Patient Continuum Services at DBHDS shared, “We see CBCS as the glue that creates a cohesive care experience for each of our patients. Some of that care is clinical, but ultimately it all always comes down to the needs of the patient at that moment and what needs to be done to support them that day.”

The Solution

DBHDS partnered with CBCS to enroll patients with a pattern of high-state psychiatric hospital utilization in the High Utilizers of Virginia (HUV) program. Through the program, enrolled patients could receive additional services that went above and beyond those offered through traditional case management. These wraparound services were provided by CBCS staff, facilitating improved care without a need to increase DBHDS headcount. Suzanne Mayo, Director of the Office of Community Integration at DBHDS, shares: “Like many others, our health system was really impacted by Covid-19, and one of the biggest challenges we’re facing is staffing. Both hiring and retaining staff has been a challenge, which ultimately impacts the services we can give at the state psychiatric hospital and creates added pressures that limit the direct care we can realistically provide. We needed the support provided by CBCS to provide the needed services that go beyond what our case management teams could offer.”

The program utilizes CBCS community workers who are available 24/7 to help enrolled members overcome barriers to care—such as helping individuals secure transportation to appointments, housing, prescribed medications, or other ancillary care needs. Additionally, CBCS works closely with other stakeholders—such as private providers or public community systems—to coordinate care and reduce redundancies in services for improved cost savings.

“There are multiple mental health systems in Virginia beyond DBHDS that our patients touch—in the community, in private practice, or through the state,” Mayo continues. “We see CBCS as the glue that holds all those pieces together to create a cohesive care experience for each of our patients. Some of that care is clinical, but it always ultimately comes down to identifying what needs each patient has in that moment and what needs to be done to support them that day.”

Collaborative programs like those offered through DBHDS are also effective for managing other conditions beyond routine mental healthcare such as substance use, opioid use, and even chronic conditions. By engaging with patients at the point of crisis, care transitions improve—as do long-term care outcomes.

Engagement—especially with a first or second follow-up visit after a crisis for any condition—really enhances treatment success. By providing good wraparound services and developing positive care relationships from the beginning, we can help patients be in a much better state and transfer to a lesser acute care coordination program quickly and effectively.

Ultimately, a successful high-utilizer program comes down to 24/7 support for acute care, immediate access to necessary wraparound services, and efficient coordination between stakeholders for better follow-up. Leveraging these key principles, bridge programs like those offered by CBCS are proving effective in supporting optimal care at the appropriate acuity level for individuals with behavioral health, substance use, opioid use, and medical diagnoses, too.

Outcomes and takeaways

The HUV program has been met with significant, measurable success. Within a year of implementation, the program achieved:

  • 97% reduction in state psychiatric hospital admissions
  • 82% reduction in state psychiatric hospital admit days
  • 30% reduction in emergency department visits
  • $2.1M in annual cost savings

Today, DBHDS is continuing to expand the program to other locales in Virginia—adapting key elements to better support the unique demographics in each community. Additionally, DBHDS has expanded member enrollment in the HUV program to include both those who have been discharged from the state hospital and those who are at risk for being admitted to the state psychiatric hospital to further prevent unnecessary high-cost utilization.

Ultimately, this program has shown that the more additional support we can provide to individuals—especially vulnerable individuals who are at high risk of ending up in institutions—the better. We have seen a lot of value in the program—financially, in services provided, and in achieved outcomes. By focusing on the little things on an individual level, it has made a huge difference overall.

About the Author

Dr. Enrique Enguidanos has over 20 years of clinical experience in Emergency Medicine, much of this time also serving in organizational and systems management roles. For well over a decade, he has developed and fine-tuned systems of care and community management systems that have proven very effective for frequent utilizers, and that is now organized in a manner that allows CBCS to continuously reproduce care results across varying communities and health care systems. Learn more about CBC Solutions by visiting


  1. The rising cost of healthcare system complexity – Accenture
  2. How do health expenditures vary across the population? – Jared OrtalizaMatthew McGoughEmma WagerTwitterGary Claxton, and Krutika Amin

Prevalence And Spending Associated With Patients Who Have A Behavioral Health Disorder And Other Conditions – By Ken Thorpe, Sanjula Jain, and Peter Joski