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 [...]

Background: Lonely adults are prone to a variety of poor health outcomes, including accelerated functional and cognitive decline, depression, and premature mortality. As a result, lonely adults may be prone to higher health-related suffering, triggering increased healthcare utilization and possibly undesired aggressive care, particularly as they approach end of life (EOL). However, little is known [...]

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, [...]

Background: While Medicare data demonstrates that healthcare spending is up to four times higher in yearly decedents than survivors, studies demonstrate that early advance care planning (ACP) leads to improved clinical outcomes and reduces cost without increase in patient anxiety or depression. Nationwide the creation of the Physician Order for Life Sustaining Treatment (POLST), a [...]