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Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
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Improving care transitions: complex high-utilizing patient experiences guide reform.

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Care management programs improved patient health and reduced hospital use for complex patients. However, overall hospital readmission rates remained unchanged, suggesting a need for external social service integration and better discharge planning.

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Area of Science:

  • Health Services Research
  • Patient Care Management
  • Healthcare Systems Analysis

Background:

  • Health systems utilize care management to enhance care quality and reduce costs through inter-level coordination.
  • Separate inpatient and outpatient care management programs existed at the academic medical center, leading to administrative silos.
  • Examining longitudinal care experiences of hospitalized complex patients was crucial to identify process and communication gaps.

Purpose of the Study:

  • To bridge administrative silos between disparate care management programs.
  • To identify process and communication gaps in the care of hospitalized complex patients.
  • To drive organizational change and improve overall patient care.

Main Methods:

  • A descriptive study analyzed the care experiences of 17 high-utilizing patients.
  • Chart audits were conducted for patients with 30-day hospital readmissions in 2013.
  • Clinical and social characteristics were reviewed for patterns influencing readmissions.

Main Results:

  • Patients presented with diverse medical, psychological, cognitive, and social factors.
  • Interventions like supervised living, depression treatment, and sobriety were associated with improved health and reduced hospital utilization.
  • Despite restructuring case management meetings to include multidisciplinary teams, hospital readmission rates remained unchanged in 2014-2015 compared to 2013.

Conclusions:

  • Longitudinal, patient-centered care management evolved from administrative silos.
  • Reducing readmissions for complex patients may necessitate external social, mental health, and substance use service integration.
  • Improved discharge planning is essential for managing complex patient populations.