Background: Healthcare system high utilizers create a financial burden raising healthcare costs and quality improvement measures should be assessed to create a positive change. We aimed to characterize the high-utilizer patients in our system to create tailored interventions to address their specific needs and ultimately reduce recurrent admissions.
Methods: A quality improvement project was implemented hospital-wide via a Plan-Do-Study- Act (PDSA) methodology. A multi-disciplinary team convened and hypothesized prior to collecting data to collaborate on suspected care gaps within our community that could improve to ultimately reduce the incidence of high utilizers. The two main care gaps that were agreed upon were the need to increase both PCP and Palliative care utilization. This hypothesis, with clear intervenable measures, was used to drive an in-depth chart review. The parameters that were used as the definition of a high utilizer was any patient with 11+ ED visits or 4+ hospital admissions within the past year. Using this definition, MRNs of all identified patients meeting the inpatient admission criteria of a high-utilizer were then compiled to perform an in-depth chart review to identify if each individual patient had on file a PCP, an advanced care note, identified as either frail or social contributing to hospital visits, and if they ultimately were still alive at time of conducting the research. Once the data was compiled measures were taken to inform local providers (via email and staff meetings) of the compelling data results to increase efforts to address this high-risk population.
Results: A total of 872 patients were identified as meeting the pre-defined criteria of an inpatient high utilizer with an average age of 64. Of the 872 total patients, 338 patients (38.8%) did not have a documented PCP at all with a total death count of 116 within the year, 34.3%. A deeper chart dive was then targeted to patients of the 8 largest local primary care offices which included a total of 422 patients. 33.4% of these patients died within the year with only 29.9% with an advanced care directive outlining their goals of care. The average number of encounters with PCP for the patients with a listed PCP was 4.0. Only 14% of the patients that met criteria for an inpatient high utilizer had significant social factors that contributed to their repeat admissions, meaning frailty was the most common contributing factor. Limitations to this data interpretation included outliers that positively skewed the data averages and the data on the free medicine clinic patients did not correlate with other practices further skewing the data.
Conclusions: This QI project was initiated to try and establish patient trends and characteristics of inpatient high utilizers that could be targeted to reduce readmissions given the burden it places on the medical system. Extensive research has been published on addressing ED high utilizers but there is scarce literature in terms of recurrent admissions. This study clearly shows that this population would benefit from both PCP and Palliative care interventions which they currently lack. The next step should be measuring whether interventions made had any significant impact.