Improving care transitions: complex high-utilizing patient experiences guide reform.

Objectives: Care management has been adopted by many health systems to improve care and decrease costs through coordination of care across levels. At our academic medical center, several care management programs were developed under separate management units, including an inpatient-based program for all patients and an outpatient-based program for complex, high-utilizing patients. To bridge administrative silos between programs, we examined longitudinal care experiences of hospitalized complex patients to identify process and communication gaps, drive organizational change, and improve care.

Study Design: This descriptive study analyzed the care experiences of 17 high-utilizing patients within the authors' health system.

Methods: Chart audits were conducted for 17 high-utilizing patients with 30-day hospital readmissions during 2013. Clinical and social characteristics were reviewed for patterns of care potentially driving readmissions.

Results: Patients had heterogeneous social factors and medical, psychological, and cognitive conditions. Care management interventions apparently associated with improvements in health and reductions in hospitalization utilization included movement to supervised living, depression treatment, and achievement of sobriety. Monthly case management meetings were restructured to include inpatient, outpatient, ambulatory care, and emergency department care managers to improve communication and process. During 2014 and 2015, hospital readmission rates were overall unchanged compared with base year 2013 among a comparable cohort of high-utilizing patients.

Conclusions: Joint review of clinical characteristics and longitudinal care experiences of high-utilizing, complex patients facilitated movement of historically siloed care management programs from their focus along administrative lines to a longitudinal, patient-centered focus. Decreasing readmission rates among complex patients may require direct linkages with social, mental health, and substance use services outside the healthcare system and improved discharge planning.