Background: Patients recurrently admitted to the hospital frequently experience fragmentation of care and poor health outcomes, with discontinuity between hospital admissions resulting in unnecessary testing, ineffective or inconsistent treatment plans, patient/provider frustration, and inability to address the underlying medical and psychosocial issues that drive repeat hospitalization.

Purpose: For patients with the highest inpatient utilization on our general medicine service, our objectives were to 1) increase continuity and care coordination, 2) identify and address the underlying drivers of hospital utilization, and 3) reduce unnecessary health care utilization.

Description: We designed and implemented a multidisciplinary intervention targeting the highest utilizers on our inpatient general medicine service. For each patient enrolled in the program, we assign an inpatient continuity team, including a hospitalist physician and nurse, to perform an in-depth review of the patient’s history and healthcare utilization patterns, solicit input from outpatient providers, and engage with the patient and his/her caregivers. The patient case is then presented to a multidisciplinary high-utilizer care committee (MHUCC), including physicians (hospitalist, emergency medicine, and psychiatry), nurses, and social workers, as well as representatives from a community health worker program, home care, and risk management. Together, the continuity team and MHUCC develop a care plan for the patient that consists of 1) a succinct medical and social history, 2) guidance for future ED, inpatient, and outpatient providers, and 3) a detailed intervention plan targeting the underlying medical and psychosocial drivers of healthcare utilization. The continuity team works with the patient, outpatient providers, and subsequent admitting teams to implement these interventions and to streamline admissions; the care plan is available to all providers via the EMR and is regularly updated by the continuity team.
We have enrolled 29 patients since the program began as a pilot in 2015, and now maintain a 15 patient active rolling census. In a pre/post analysis comparing the six months pre and post intervention, admissions and total hospital days were reduced by 55% and 47% respectively, and thirty-day readmissions were reduced by 65% (n=19 patients with a complete six months of follow up); total direct costs were reduced from $2,923,000 to $1,284,000 (n=16). Pre/post analysis comparing the 12 months pre and post intervention demonstrates a sustained effect, with reductions in admissions, total hospital days, and thirty-day readmissions of 55%, 56%, and 67%, respectively (n=14). Providers describe improved consistency, decreased frustration, and in some cases, facilitation of previously delayed diagnostic or therapeutic procedures.

Conclusions: A multidisciplinary and highly individualized approach is essential to developing successful interventions for patients with the highest hospital utilization; while resource intensive, this intervention demonstrates return on investment given the significant costs of repeat hospitalization among this group. The program’s greatest strengths lie in our abilities to build trust, create consensus among providers, advocate for large scale interventions, and provide continuity and coordination over time. Investing in a consistent core team to support the program and provide extensive care coordination both during and between admissions is key to program success.