Background: Patients recurrently admitted to the hospital account for a disproportionate percentage of hospital costs and frequently experience fragmentation of care and poor health outcomes. On our hospitalist service at a large academic medical center, patients admitted five or more times per year make up less than 1% of patients but approximately 5% of admissions. For these “high utilizers,” continuity between hospital admissions is often low, leading to unnecessary testing,  ineffective or inconsistent treatment plans, and patient/provider frustration.  Additionally, there is no process in most hospitalist programs to explicitly address the medical and psychosocial issues that drive repeat hospitalization for the high utilizer population.

Purpose: Our goal was to develop individualized care plans for patients with the highest inpatient utilization on our hospitalist service using a multidisciplinary approach designed to coordinate care, improve continuity, address the underlying drivers of hospital utilization, and ultimately reduce unnecessary health care costs.

Description: We designed and implemented a multi-component intervention to target the highest utilizers on the hospitalist service. The intervention included  assignment of an inpatient continuity team (including a hospitalist physician and a nurse), development of a continuity care plan for each patient, and creation of a multidisciplinary high-utilizer care committee (MHUCC) to direct the program and assist in addressing the drivers of hospital utilization. The continuity team performs an in-depth review of the patient’s history and healthcare utilization patterns, solicits input from existing outpatient providers, and works with the MHUCC to develop a continuity care plan for the patient. The MHUCC includes physicians (hospitalist, emergency medicine, psychiatry, and pain management), nurses, and social workers, as well as representatives from a community health worker program, home care services, and risk management. The continuity team then works with outpatient providers and subsequent admitting teams to implement the proposed interventions. The continuity care plan, which is made available to providers in the EMR and is iteratively updated by the continuity team, consists of  guidance for ED, inpatient, and outpatient providers and a detailed plan for addressing underlying medical and social drivers of high utilization. Nine patients have been enrolled to date, with initial pooled results showing a 32% drop in admissions and 35% drop in days hospitalized compared to the 12 months prior to enrollment; providers also note improved consistency, decreased frustration, and in some cases, facilitation of previously delayed diagnostic or therapeutic procedures.

Conclusions: An individualized and multidisciplinary approach to care coordination and inpatient continuity shows great promise in decreasing healthcare utilization among a diverse group of high utilizer patients on a hospitalist service.