Background: Coordination of inpatient and outpatient care is an important challenge in improving population health but evidence examining the effectiveness of existing care coordination programs is mixed. The Comprehensive Care Physician (CCP) Program at the University of Chicago provides patients at increased risk of hospitalization the opportunity to receive inpatient and outpatient care from the [...]

Background: Coordination of inpatient and outpatient care is an important challenge in improving population health but evidence examining the effectiveness of existing care coordination programs is mixed. The Comprehensive Care Physician (CCP) Program at the University of Chicago provides patients at increased risk of hospitalization the opportunity to receive inpatient and outpatient care from the [...]

Background: High health care costs and poor outcomes are associated with high hospitalization rates and are concentrated in a small fraction of the population. Fragmented patient care and socioeconomic disadvantage may further increase hospitalization rates. To defragment medical care for a socioeconomically diverse population of Medicare patients at increased risk of hospitalization, the University of [...]

Background: High need patients are characterized by medical complexity, high amounts of health acute care utilization and disproportionate costs[1]. Recent studies have characterized worsening of loneliness in the general population, however, it has not been characterized in the high need population. We hypothesized that increases in loneliness would be associated with increasing symptoms of depression; [...]

Background: For patients at increased risk of hospitalization, reducing hospitalization is often a key objective and can have important effects on health care costs. The Comprehensive Care Physician (CCP) model was developed originally at the University of Chicago to reintegrate inpatient and outpatient care under the same physician for patients at high risk of hospitalization [...]

Background: Chronic Obstructive Pulmonary Disease (COPD) is the 4th leading cause of death and a major driver of healthcare utilization worldwide. Established guidelines exist for hospitalized patients with COPD yet adherence to these has been found in multiple studies to be low. Our question is which Quality Improvement system changes best reduce healthcare utilization and [...]