When a 56-year-old Kaiser Permanente member, who was living with diabetes, heart failure, and untreated depression, walked into the Kaiser Permanente Sacramento Emergency Department for the ninth time in six months, his care team recognized more than a familiar face. They saw a chance to break the cycle. His frequent visits told a deeper story of housing struggles, unreliable transportation, and a lack of mental health support. These challenges are all too familiar among high utilizers, a small group whose needs drive a large share of ED visits and resources.
To tackle these layered challenges, the High Utilizer Interdisciplinary Team brings together Care Without Delay (CWD), Continuum of Care, and ED leaders to craft personalized care plans that go beyond medicine. By weaving together the skills of nurses, social workers, psychiatrists, primary care providers, pharmacists, and community partners, the team meets each patient’s needs from every angle.
“This work exemplifies interdisciplinary care at its best,” said Keith Weaver, MSN, RN, NEA-BC, CWD Program Director. “By bringing together multiple disciplines, we’re addressing not just the symptoms but the root causes that bring patients to the ED time and again.”
Leading this work are Aaron Willits, CWD Manager, who co-leads the High Utilizer Committee and maintains accountability and structure across disciplines; Kelly Lattimer, MSW, whose expertise in social work ensures patients are connected to critical community resources; and Syed Arshad, MD, Physician Lead, who provides clinical oversight to ensure interventions are both evidence-based and patient-centered.
Each patient’s care plan is documented in the electronic health record, providing visibility across care settings. Automated alerts notify the CWD team when a high utilizer presents to the ED, triggering timely, coordinated interventions.
As of August 2025, early results demonstrate meaningful progress. ED visits decreased from an average of 64 to 58, and Observation Care Team encounters dropped from 6 to 5. Inpatient average stays reflecting incremental improvements.
“This is integrated care in action,” said Esperanza Chavez, MSA, BSN, RN, NEA-BC, Chief Nurse Executive, Sacramento. “When disciplines collaborate, we deliver compassionate, consistent care that transforms lives and advances our mission of equitable, patient-centered care.”
Even modest reductions in ED and observation visits represent significant progress toward sustainable, coordinated, and compassionate care, evidence that when teams work together across disciplines, the impact extends far beyond the ED doors.