The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center.

BACKGROUND: High utilizers are medically and psychosocially complex, have high rates of emergency department (ED) visits and hospital admissions, and contribute to rising healthcare costs.
OBJECTIVE: Develop individualized care plans to reduce unnecessary healthcare service utilization and hospital costs for complex, high utilizers of inpatient and ED care.
DESIGN: Quality-improvement intervention with a retrospective pre/post intervention analysis.
SETTING: Nine hundred twenty-four-bed tertiary academic medical center. PATIENTS: Twenty-four medically and psychosocially complex patients with the highest rates of inpatient admissions and ED visits from August 1, 2012 to August 31, 2013. INTERVENTION: A multidisciplinary team developed individualized care plans integrated into our electronic medical record (EMR) that summarize patient histories, utilization patterns, and management strategies. MEASUREMENTS: Primary 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.
RESULTS: Hospital 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.
CONCLUSIONS: Individualized 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.