High Utilizer Care Plan Project: A Network Initiative to Decrease Inappropriate Resource Utilization Among High-Risk...

Healthcare costs in the United States continue to rise. Among many factors, this can be attributed to a small subset of the overall patient population, termed "high utilizers" (HUs). HUs account for nearly 50% of health care costs. The costs associated with HUs tend to be disproportionate, often unnecessary, and not associated with improved patient outcomes. The excessive utilization of resources by HUs is multifactorial, requiring innovative and multifaceted solutions. Our institution implemented a comprehensive program to not only identify HUs but also to address the identified underlying clinical and social determinants in order to provide appropriate care while reducing resource overuse. We hypothesized that a robust quality improvement process coupled with individualized care plans (ICPs) would result in effective identification of HUs and decrease associated costs.

From July 2021 to July 2025, a multidisciplinary team identified patients as HUs based on existing Department of Health and Human Services definitions. The team then created ICPs for each patient. These care plans were linked to the patient's electronic medical record (EMR) and appeared each time a provider accessed the EMR. The cost per patient and usage of inpatient, outpatient, and Emergency Department (ED) facilities were measured. Aggregate endpoints were captured six months prior to ICP initiation and six months after ICP implementation, and the final endpoint was taken at the last six months of the study, regardless of how long the patient was on their ICP. In addition to descriptive statistics, temporal and group comparisons were performed using STATA software (StataCorp, College Station, TX, USA), with a Bonferroni correction applied and significance set at P<0.017.

A total of 190 patients were enrolled in ICPs over the study period. The mean age was 45.15 years, and the majority of the patients (62.6%) were female sex. Following the implementation of ICPs, there was a $40.91 million reduction in charges over the four-year course of the study. Overall, there were statistically significant decreases in ED visits (14.18 to 6.75 mean visits), inpatient visits (4.43 to 2.41 mean visits), and inpatient imaging (9.35 to 5.41 mean studies) using the beginning of the ICP as a starting point and the most recent six months snapshot as the endpoint.

High utilizers contribute to unacceptably high healthcare expenditures. This study shows that a hybrid approach consisting of a multidisciplinary team, standardized definitions, technology-aided protocols to identify HU, and ICPs effectively reduces costs as well as ED and inpatient visits. This approach also reduces unnecessary imaging.