Background: Nationally, a minority of patients with complex medical and psychosocial needs consume a disproportionate amount of healthcare. In the U.S. in 2015, the top 1% of the population accounted for 23% of all healthcare expenditures and cost ten times more per year than the average patient. No one disease accounts for a large percentage, therefore disease-specific interventions are unlikely to work to reduce unnecessary utilization. A novel approach using individualized care plans (ICPs) has been deployed successfully with reductions in inpatient utilization patterns at large urban-based hospitals but to our knowledge has not been replicated in a non-urban setting. In 2016, a small cohort of patients with sickle cell disease (SCD) were identified (based on weekly review of all readmissions) as a high utilizer (HU) population who accounted for 7% of all readmissions to the general medicine services and nearly $1 million in annual costs.
Purpose: For this cohort of patients with SCD and high inpatient utilization, our objectives were to 1) improve consistency of pain management between hospital encounters 2) increase multidisciplinary collaboration to address underlying drivers of hospitalization 3) reduce harm through behavioral management plans and 4) reduce unnecessary health care utilization.
Description: Beginning early 2017, a multidisciplinary team collaborated to create longitudinal ICPs for nine HU patients with SCD. Plan development included extensive chart review, meeting with each patient to prompt his/her input, and soliciting recommendations from multiple physician and non-physician disciplines for a 360-degree view of each patient. The result is a concise summary of each patient’s medical and social history and prior utilization that outlines detailed strategies for optimal care across the inpatient-outpatient continuum; in essence, a roadmap to care for a “common presentation” of the patient’s chronic illness, with focus on complex pain and behavioral management. Once finalized, ICPs were made available in the EMR for use by inpatient, outpatient, and emergency department providers. In a pre-post analysis of the pilot cohort comparing the four quarters pre and post intervention (as marked by the implementation of seven of the nine eventual ICPs), admissions and hospital bed days were reduced by 64% and 43%, respectively, and thirty-day readmissions were reduced by 76%. Total costs were reduced by 24% from $949,935 to $717,226. Following implementation, with a sustained effect for one year, this cohort accounts for <2% of the general medicine thirty-day readmissions. Anecdotally, many patients have praised the improvement in the consistency of their care and providers have expressed appreciation for the effectiveness of ICPs in facilitating care of complex patients. Prior to the pilot, IV line manipulation and opioid diversion resulting in patient harm were quite prevalent in this population. Fortunately, since ICP implementation there has only been one suspected incident of patient harm due to line manipulation.
Conclusions: Patients with high utilization patterns require a multidisciplinary and individualized approach. ICPs are an effective strategy to improve consistency of care and reduce unnecessary hospital utilization among HU patients with sickle cell disease, even in a non-urban hospital setting. This approach requires considerable time investment by a dedicated team, but has significant potential return on investment to health systems, care providers, and patients.