• Tim Mercer, Jon Bae, Joanna Kipnes, Maureen Velazquez, Samantha Thomas, and Noppon Setji.
• Internal Medicine & Pediatrics Residency Program, Duke University Medical Center, Durham, North Carolina.
• J Hosp Med. 2015 Jul 1; 10 (7): 419424419-24.

BackgroundHigh utilizers are medically and psychosocially complex, have high rates of emergency department (ED) visits and hospital admissions, and contribute to rising healthcare costs.ObjectiveDevelop individualized care plans to reduce unnecessary healthcare service utilization and hospital costs for complex, high utilizers of inpatient and ED care.DesignQuality-improvement intervention with a retrospective pre/post intervention analysis.SettingNine hundred twenty-four-bed tertiary academic medical center.PatientsTwenty-four medically and psychosocially complex patients with the highest rates of inpatient admissions and ED visits from August 1, 2012 to August 31, 2013.InterventionA multidisciplinary team developed individualized care plans integrated into our electronic medical record (EMR) that summarize patient histories, utilization patterns, and management strategies.MeasurementsPrimary outcomes included inpatient admissions, ED visits, and corresponding variable direct costs 6 and 12 months after care-plan implementation. Secondary outcomes include inpatient length of stay (LOS) and 30-day readmissions.ResultsHospital admissions decreased by 56% (P < 0.001) and 50.5% (P = 0.003), 6 and 12 months after care-plan implementation. Thirty-day readmissions decreased by 66% (P < 0.001) and 51.5% (P = 0.002), 6 and 12 months after care-plan implementation. ED visits, ED costs, and inpatient LOS did not significantly change. Inpatient variable direct costs were reduced by 47.7% (P = 0.001) and 35.8% (P = 0.052), 6 and 12 months after care-plan implementation.ConclusionsIndividualized care plans developed by a multidisciplinary team and integrated with the existing healthcare workforce and EMR reduce hospital admissions, 30-day readmissions, and hospital costs for complex, high-utilizing patients.© 2015 Society of Hospital Medicine.

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