Individualized Care Plans for High Utilizers.

Area of Science:

• Quality Improvement
• Health Services Research
• Patient Care Management

Background:

• Frequent hospital admissions by a small patient group ('high utilizers') disproportionately consume healthcare resources.
• Effective strategies are needed to manage high utilizers and optimize hospital capacity.

Purpose of the Study:

• To assess the impact of implementing individualized care plans (ICPs) on hospital resource utilization among high-utilizing patients.
• To determine if ICPs can reduce admissions and hospital days while maintaining or improving patient care.

Main Methods:

• A quality improvement project identified high utilizers via electronic health records (EHR).
• A hospitalist workgroup selected younger, frequently admitted low-risk patients for ICP development.
• Individualized care plans (ICPs) were created in the EHR and made easily accessible.

Main Results:

• Total annual admissions per patient decreased by 67% (from 125 to 41).
• Annual hospital days per patient decreased by 56% (from 497 to 219).
• Average length of stay increased by 26% (from 4 to 5.4 days).

Conclusions:

• Individualized care plans (ICPs) are effective in reducing hospital resource utilization for high-utilizing patients.
• Accessible ICPs facilitate better patient management, allowing more time at home and freeing hospital resources.
• This approach demonstrates a successful quality improvement strategy for managing frequent admissions.