High–volume, high–cost patients pose a challenge to healthcare institutions due to fragmented care, socioeconomic issues,and lack of outpatient resources. Recently, New York’s Medicaid program adopted a measure to reduce payment to hospitals with a potentially preventable readmission rate higher than a state benchmark, leading hospitals to explore new methods for preventing readmissions. To this end, we convened a multidisciplinary team (Complex Care Committee, or CCC) to design personalized care plans for these complex patients that would translate throughout all acute care visits.


To identify high–volume users and develop a process for creating longitudinal care plans that would be implemented at the time of Emergency Department (ED) arrival so as to optimize care yet decrease readmissions and length of stay.


Using financial data, we compiled a report stratifying patients by cost and by number of hospital admissions. Two patients from this report are selected for review at the biweekly CCC meeting if they had greater than 3 admissions over 3 months. The CCC, comprised of ED physicians, case managers, social work, admission specialists, hospitalists, residents as well as representatives from pain management, psychiatry and palliative care, designated the following as success outcomes: (1) a reduction in the number of admissions to less than 1 hospital admission per month (2) reduction of length of stay and (3) increased number of days between readmissions. Input is obtained from committee members and the primary care physician regarding the medical and social history, therapeutic interventions and key consultants. Following discussion, a care plan is created and placed on a password protected share drive for access by physicians. Because the ED has an electronic medical record (EMR) and is independent of the hospital system, key components from the care plan are placed into the ED record for reference by the ED physician. Some interventions for these patients include designating the same hospitalist across all hospital visits, predetermined pain regimens for sickle cell crisis to be started in the ER, and prepaid patient phones at time of discharge. To promote early intervention of CCC patients, we designed an email alert system, which is initiated by the admissions specialists at time of presentation of a CCC patient to the ED. At each CCC meeting, updates on all CCC patients are discussed and care plans are modified accordingly.


From August 2011 to November 2011, we have prevented readmission to the hospital or decreased length of stay in five of 22 reviewed cases. Of these five cases, three were Medicare and 1 was Medicaid. No unifying reason for readmission was found, thus requiring a unique care plan for each patient. By initiating interventions at time of presentation and coordinating care across hospital visits, early data shows that targeting high–volume patients in this manner is an effective approach to patient care.