Intervening With and Improving Care for Patients at Risk for Frequent Hospital Admissions
| Status: | Completed |
|---|---|
| Conditions: | Hospital |
| Therapuetic Areas: | Other |
| Healthy: | No |
| Age Range: | 18 - 64 |
| Updated: | 4/21/2016 |
| Start Date: | August 2007 |
| End Date: | March 2009 |
Patients with frequent hospital admissions account for a disproportionate share of visits
and costs. An intervention that can bridge the gap between hospital and community based care
for a population of patients with frequent hospital admissions may offer both improved care
and cost savings if hospital admissions can be appropriately reduced. We are now using data
from our previous research to inform the development and implementation of an intervention
at Bellevue Hospital, which will bridge the gap between hospital and community based care
for a population of patients with frequent hospital admissions.
We hypothesize that such an intervention can offer both improved care and cost savings if
hospital admissions can be appropriately reduced.
In this protocol we outline a strategy to pilot a small-scale intervention on a small subset
of patients admitted to an urban public tertiary care safety net hospital who are defined by
our study criteria as at high risk for future readmission. By piloting components of the
intervention, we aim to assure the intervention functions as planned, and can deliver the
needed services to high risk patients in a seamless and patient-centered manner. The purpose
of this "feasibility study" is to ensure that when our intervention is implemented on a
larger scale, it appropriately serves enrolled patients needs, and that we are able to
effectively follow patients during the intervention period.
and costs. An intervention that can bridge the gap between hospital and community based care
for a population of patients with frequent hospital admissions may offer both improved care
and cost savings if hospital admissions can be appropriately reduced. We are now using data
from our previous research to inform the development and implementation of an intervention
at Bellevue Hospital, which will bridge the gap between hospital and community based care
for a population of patients with frequent hospital admissions.
We hypothesize that such an intervention can offer both improved care and cost savings if
hospital admissions can be appropriately reduced.
In this protocol we outline a strategy to pilot a small-scale intervention on a small subset
of patients admitted to an urban public tertiary care safety net hospital who are defined by
our study criteria as at high risk for future readmission. By piloting components of the
intervention, we aim to assure the intervention functions as planned, and can deliver the
needed services to high risk patients in a seamless and patient-centered manner. The purpose
of this "feasibility study" is to ensure that when our intervention is implemented on a
larger scale, it appropriately serves enrolled patients needs, and that we are able to
effectively follow patients during the intervention period.
In pilot research, we found that high users at Bellevue Hospital Center had varied
indications for admission to the hospital, but also shared many risk factors that have been
traditionally difficult for the health care system to address, including homelessness,
social isolation, substance use, depression and anxiety, and fragmented primary care.
Coordination of the multiple service types required to improve care for such patients across
hospitals, clinics, and community-based organizations is hindered by financial
disincentives, restrictive funding streams, and poor communication among service providers
Intervention model and team: The pilot intervention will begin at the patient's bedside in
the hospital and continue after his/her discharge into the community, utilizing a flexible
and intensive care management model with a multi-disciplinary team approach. Community Based
Care Managers (CBCMs) overseen by a social worker, will connect patients to needed community
services including housing for homeless patients, accompany patients to appointments and
facilitate transportation to medical, benefits enrollment, and perform other services based
in the hospital and community.
So that the intervention can address the multitude of complex medical and social needs of
high risk patients, in addition to our community partners that address the needs of homeless
patients, we will partner with additional community providers of mental health, substance
use, and home medical services who will assist our intervention team staff in managing
patients' care after hospital discharge. In addition, we will build upon existing
specialized health and social services within Bellevue Hospital (e.g. provision of prompt
outpatient clinic appointments) so that this population is better and more effectively
served.
Specific Aims
1) evaluate the patient and provider experience with various potential components of a pilot
intervention plan for high risk, high cost patients, (identified using a predictive
case-finding algorithm) conducted in partnership with community providers of homeless,
mental health, substance use, and other key services, and 2) evaluate the feasibility of
several aspects of the intervention. By piloting and evaluating components of the
intervention, we aim to assure the intervention functions as planned, and can deliver the
needed services to high risk patients.
Outcomes:
Ability of intervention team to:
1. Function effectively (e.g. communicate and coordinate with one another and with other
departments in the hospital)
2. Match patients to appropriate services
3. Obtain supportive housing for homeless patients with Common Ground partner
4. Maintain contact with patients after initial hospital discharge
5. Facilitate patient adherence to outpatient appointments
6. Link patients with no usual source of care to PMD
indications for admission to the hospital, but also shared many risk factors that have been
traditionally difficult for the health care system to address, including homelessness,
social isolation, substance use, depression and anxiety, and fragmented primary care.
Coordination of the multiple service types required to improve care for such patients across
hospitals, clinics, and community-based organizations is hindered by financial
disincentives, restrictive funding streams, and poor communication among service providers
Intervention model and team: The pilot intervention will begin at the patient's bedside in
the hospital and continue after his/her discharge into the community, utilizing a flexible
and intensive care management model with a multi-disciplinary team approach. Community Based
Care Managers (CBCMs) overseen by a social worker, will connect patients to needed community
services including housing for homeless patients, accompany patients to appointments and
facilitate transportation to medical, benefits enrollment, and perform other services based
in the hospital and community.
So that the intervention can address the multitude of complex medical and social needs of
high risk patients, in addition to our community partners that address the needs of homeless
patients, we will partner with additional community providers of mental health, substance
use, and home medical services who will assist our intervention team staff in managing
patients' care after hospital discharge. In addition, we will build upon existing
specialized health and social services within Bellevue Hospital (e.g. provision of prompt
outpatient clinic appointments) so that this population is better and more effectively
served.
Specific Aims
1) evaluate the patient and provider experience with various potential components of a pilot
intervention plan for high risk, high cost patients, (identified using a predictive
case-finding algorithm) conducted in partnership with community providers of homeless,
mental health, substance use, and other key services, and 2) evaluate the feasibility of
several aspects of the intervention. By piloting and evaluating components of the
intervention, we aim to assure the intervention functions as planned, and can deliver the
needed services to high risk patients.
Outcomes:
Ability of intervention team to:
1. Function effectively (e.g. communicate and coordinate with one another and with other
departments in the hospital)
2. Match patients to appropriate services
3. Obtain supportive housing for homeless patients with Common Ground partner
4. Maintain contact with patients after initial hospital discharge
5. Facilitate patient adherence to outpatient appointments
6. Link patients with no usual source of care to PMD
Inclusion Criteria:
- Patients identified at the time of a current hospital admission by a predictive
algorithm (algorithmic risk score of 50 or greater) as being at high risk for
hospital readmission in the following 12 months
- English or Spanish speaking
- Fee-for-service Medicaid or uninsured patients
- Ages 18-64
Exclusion Criteria:
- Neither English or Spanish-speaking,
- Institutionalized when not admitted to the hospital
- Unable to communicate
- HIV positive (because HIV positive patients have resources available to them from
different and unrelated funding streams, and receive primary care at an off-site
location)
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