There are always a small number of patients frequently visit Emergency Department (ED) and are frequently admitted to the hospital. The underlying reasons are sometimes medical conditions and sometimes are complex psychological and social issues. Formulating a care plan that is individualized for a patient with appropriate support from healthcare professionals may help to decrease utilization of healthcare services and resources by such patients.
A study published in this month’s Journal of Hospital Medicine examined the same question. Investigators formed a multidisciplinary team that developed individualized care plans integrated into electronic medical record (EMR) that summarized patient histories, utilization patterns, and management strategies. They enrolled 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.
Investigators found that 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.
At least this one study found that 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.
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