Frequent flyers in the airline industry generally are considered to be a good thing. Passengers rack up miles, or points, and redeem them for air travel and other perks. The airline, meanwhile, gains loyal customers.

Frequent flyers or "super users" in the health care industry, however, comprise a trend that many would like to change. Repeated ambulance trips to the emergency room may mean a patient has a chronic condition that isn't being treated properly. If their ailment is not serious, then the patient may be tying up ambulance and emergency room services and delaying help for someone in serious need.

That's where veteran Rockford firefighter Trent Brass, 43, gets involved. He manages the Mobile Integrated Healthcare Program, a joint venture of the Rockford Fire Department and SwedishAmerican Hospital.

Brass, who also is a respiratory therapist at SwedishAmerican Hospital, joined the program in August. About 25 patients are enrolled.

Brass along with a SwedishAmerican nurse or doctor travel weekly to patients' homes to help them manage their health care.

"We focus on patients who have a history of chronic obstruction pulmonary disease, diabetes, recent heart attack, stroke or congestive heart failure," Brass said. "These individuals are high-risk for re-admissions or high-risk for utilizers of the emergency department."

A home visit will include a health assessment and determining why a patient frequently uses an ambulance and the ER, but often fails to keep doctor appointments. A lack of transportation is an issue for some, Brass said. Some patients frequently find themselves in need of emergency services because they fail to take their medicines as prescribed, and others, he said, may call an ambulance or visit the ER simply because they have very little interaction with others.

"The goal is to help them better manage their health through education, case management and community resource support," he said. "This community is very resource rich. A lot of times it's just trying to help navigate people to those resources."
