Background: Frequently hospitalized patients represent a vulnerable population due to discontinuity between episodes of inpatient, outpatient, and specialty care. This discontinuity puts patients at risk for unnecessary over-treatment, dangerous under-treatment, medication errors, and loss of trust due to conflicting messages from healthcare providers. Providers face rising clinical volumes, decreasing familiarity between providers, and ever more complex electronic record systems. This results in communication gaps widened by inaccurate copy forwarding, difficult to find test results, and incorrect charting. Each of these factors may impede provider attempts to coordinate care for this complex and vulnerable patient population.

Purpose: To improve the care of frequently hospitalized patients at our institution, we created a comprehensive care plan. This tool includes accurate patient history, management recommendations for each patient’s medical conditions, pain, and behavior, and information necessary to coordinate multidisciplinary care across multiple settings.

Description: In 2015, the Complex High Admission Management Program (CHAMP) was created at Northwestern Memorial Hospital to improve the care of the most frequently hospitalized patients. Initially started as a program to reduce penalty readmissions, CHAMP has grown into a comprehensive, longitudinal, relationship-based program which partners with patients in order to improve their care. The program’s hallmark is the unique care plan written for each patient at the time of enrollment. Each care plan is created with patient input, and incorporates medical, behavioral, and pain management recommendations as well as logistical considerations for optimal care transitions within the healthcare system. It is formatted to provide focused, relevant recommendations for each potential patient location within the healthcare system. The care plan is frequently updated as the patient’s clinical status, psychosocial situation, and goals evolve. In response to feedback from providers and patients, the care plan has evolved into a succinct tool for communication and advocacy. Integration within the electronic medical record facilitates easy just-in-time access for providers. In our experience, patients with care plans report decreased variability in their care, stronger communication with their healthcare teams, and improved satisfaction with their healthcare experiences. Providers report feeling more adequately prepared to manage each patient’s care, more supported in caring for complex patients, and less reluctant to engage challenging patients.

Conclusions: When used for frequently hospitalized patients, comprehensive care plans decrease variability in care, avoid unnecessary admissions, reduce redundant testing, and improve patient engagement and satisfaction with medical care.