High Touch, High Trust: Using Community Health Advocates and Lawyers to Address ED High Utilizers

Kalpana N. Shankar
Julianne N. Dugas
JoHanna Flacks
Megan Cole Brahim
Samantha Morton
Thea James
Patricia Mitchell
Peer-Reviewed Article
July 2022


Social and legal services to address health care costs and utilization may be most effective for individuals with moderately high utilization who are less clinically complex.


Initiatives to reduce emergency department (ED) utilization among individuals who excessively use health care services in EDs should also address patients’ social and economic needs. A safety-net hospital created a “High Touch High Trust” program to connect patients with high ED utilization (defined as four or more visits in the prior six months) to basic legal aid and care management services provided by community health advocates. This study used a pre-post analysis to evaluate whether program participation was associated with improved social outcomes as well as lower health care utilization and costs.


While program participants did not have significantly different rates of ED admissions or costs after enrolling in this program, they did experience increased outpatient costs. Notably, the patients who benefited the most from this program were those who presented with under six ED visits in the last six months, but this sample size was too small to calculate statistical significance. The program addressed approximately 18 – 45 percent of the social issues that were identified by the community health advocates and approximately 10 – 58 percent of identified legal issues.


Programs seeking to decrease health care utilization by focusing primarily on social and legal needs may be less effective for patients with the highest levels of past ED use, since those patients are more medically complex.

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