The Highest Utilizers of Care: Individualized Care Plans to Coordinate Care, Improve Health Care Service Utilization and Reduce Costs at an Academic Tertiary Care Center

1Duke University Medical Center, Durham, NC

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 123

Background:

High utilizers of health care services are psychosocially complex patients with significant medical and psychiatric co‐morbidity and higher mortality rates. They account for a disproportionately high number of emergency department (ED) visits, inpatient admissions, and health care costs. This quality improvement (QI) intervention creates individualized care plans to coordinate care and reduce unnecessary health care service utilization for a group of complex, high utilizing patients at an academic tertiary care center.

Methods:

The Complex Care Plan Committee, a multidisciplinary team from hospital medicine, emergency medicine, psychiatry, ambulatory care, nursing and social work, develops care plans for high utilizing patients. Patients are selected based on complexity and hospital utilization rates. These care plans summarize the patient’s history, disruptive behaviors, and utilization patterns, and propose a standardized approach to triaging and caring for them. Care plans are readily visible in the electronic medical record and an automatic notification alerts the admitting medicine hospitalist and ED providers that a high utilizer has arrived. This QI project and retrospective review was granted exempt status from our IRB.

Results:

Preliminary data was analyzed for 14 patients between 8/1/2012 to 4/1/2013 covering equal time frames before and after care plan implementation; final analysis will include data 6 months before and after care plan implementation for 24 patients. Payor mix was 50% Medicaid, 14% Medicare, 29% Medicaid/Medicare, and 7% self‐pay. ED visits increased from 184 to 205 after care plan implementation, however a single patient accounted for 150 ED visits over 9 months. Total admissions decreased from 82 to 33 after care plan implementation, a 60% reduction, and 30‐day readmissions decreased from 53 to 15, a 72% reduction. Inpatient length of stay (LOS) also decreased, from a total of 393 days to 163 days for all 14 patients. ED variable direct costs (VDC) and total costs increased after care plan implementation, largely driven by the single patient with 150 ED visits. There was a 44% reduction in each inpatient VDC per patient, total VDC, and total costs. The sum of ED and inpatient VDC decreased from $468,814 to $307,845 after care plan implementation, a 34% reduction.

Conclusions:

Individualized care plans reduced inpatient utilization rates and health care costs for a group of complex, high utilizing patients at our academic, tertiary care center. Next steps include increasing coordination with outpatient providers to determine if this hospital‐based intervention impacts care coordination, utilization rates and cost throughout the health care system.

Utilization patterns before and after care plan implementation



All Patients on Care Plans (N=14) Pre Care Plan Post Care Plan % Change
Total ED visits 184 205* 11%
Total Admissions 82 33 ‐60%
30 Day Readmissions 53 15 ‐72%
Mean number of admissions per patient 5.9 2.4 ‐59%
Sum of Inpatient LOS days 393 163 ‐59%
*ED visits increased due to a single patient returning 150 times over 9 months

Health care costs before and after care plan implementation



All Patients on Care Plans (N=14) Pre Care Plan Post Care Plan % Change
ED Costs
VDC per patient $3,611 $4,124 14%
Sum total of VDC $50,557 $57,737 14%
Sum of Total Cost $120,325 $143,860 20%
Inpatient Costs
VDC per patient $24,975 $13,918 ‐44%
Sum total of VDC $349,643 $194,850 ‐44%
Sum of Total Cost $772,920 $431,640 ‐44%
Sum of ED and Inpatient VDC $468,814 $307,845 ‐34%

To cite this abstract:

Mercer T, Bae J, Setji N, Velazquez M. The Highest Utilizers of Care: Individualized Care Plans to Coordinate Care, Improve Health Care Service Utilization and Reduce Costs at an Academic Tertiary Care Center. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 123. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/the-highest-utilizers-of-care-individualized-care-plans-to-coordinate-care-improve-health-care-service-utilization-and-reduce-costs-at-an-academic-tertiary-care-center/. Accessed November 22, 2019.

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