Background: A small number of patients account for a disproportionate number of hospital readmissions. The Complex High Admission Management Program (CHAMP) is designed to improve care and reduce hospitalizations for frequently readmitted patients. Non-randomized studies of CHAMP found reductions in readmission but may be subject to regression to the mean. We conducted a randomized trial [...]

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: Frequently hospitalized patients face unique challenges in navigating health care systems. Although practice-, hospital-, and accountable care organization-level programs to address the needs of these patients exist, interventions have had mixed results, with only some demonstrating reduction in hospitalizations or costs. To best serve frequently hospitalized patients and improve future interventions, clinicians, leaders, and [...]

Background: Health-related social needs (HRSN) exacerbate poor health in patients with chronic medical conditions. The population of frequently hospitalized patients is heterogeneous, but many have unmet health related social needs. Multidisciplinary programs for this population emphasize longitudinal patient-provider relationships and intensive case management. Studies of these interventions have failed to demonstrate improved readmissions outcomes but [...]

Background: A small number of patients account for a disproportionate number of hospital readmissions. The Complex High Admission Management Program (CHAMP) is designed to improve care and reduce hospitalizations for frequently readmitted patients. Non-randomized studies of CHAMP found reductions in readmission but may be subject to regression to the mean. We conducted a randomized trial [...]