The Lehigh Valley Super Utilizer Partnership (LVSUP) provides intensive outreach and care coordination for patients with complex illness who have been admitted to the hospital two or more times in the past 6 months. Our goal is to help patients learn to navigate the complicated world of health care, strengthen connections with their clinicians, and set and accomplish goals that improve their quality of life.

By definition, a super-utilizer program is a targeted, high-intensity, and patient-centered primary care team that is data driven, and assists patients in community and healthcare navigation, while encouraging patient self-advocacy. This program approach, pioneered by Dr. Jeffrey Brenner in Camden, NJ, has been shown to improve care outcomes and reduce costs for individual patients with high inpatient and emergency department (ED) use.

Medicaid consumes over 31 percent of Pennsylvania’s annual budget, providing services for approximately 17 percent of its residents, roughly 2.2 million individuals. Pennsylvania also spends significantly on long-term care services, ranking fourth highest among all U.S. states in this category. These costs present an unsustainable burden for the state, its taxpayers, and the hospitals and providers serving the Medicaid population. Our challenge and opportunity is to change how we engage, treat, and partner with high-cost patients and across our communities to achieve better outcomes through more cost effective care.


Our team: Top, left to right: Lisa (Parish Nurse), Luz (Community Health Worker), Evelyn (Social Worker), Elisa (Community Health Worker). Bottom, left to right: Carmen (Licensed Practical Nurse), Francigna (Research Assistant), Jewel (Community Connector), Janelle (Community Exchange Liaison)