A simple plan for complex patients

Care plans guide treatment of high utilizers.

The care management program for high-utilizing patients at St. Paul, Minn.-based Regions Hospital launched about 5 years ago, fueled by a recurring treatment frustration likely familiar to any hospitalist.

“Even though these patients come in so frequently, they are the hardest ones to get your head around,” said Rick Hilger, MD, medical director of care management at Regions, part of the nonprofit health care organization HealthPartners.

Photo by Thinkstock
Photo by Thinkstock

Doctors would work to sort through towering stacks of medical records or, more recently, numerous electronic screens. One patient with a history of heart disease and a severe anxiety disorder came to the hospital 49 times—including emergency visits and hospital admissions—in a single year. “There are so many pages to try to click on that it is luck or unluck if you find the key piece of information to help you make the right [treatment] decision,” Dr. Hilger said.

Hospitalists have long struggled with treatment of this small but very costly group, once dubbed “frequent fliers” and now more typically called super- or high utilizers. Along with straining physician time and patience, caring for this group places a disproportionate burden on the health care system. In the Medicaid program alone, 5% of patients accounted for 48% of the program's spending in fiscal year 2011, according to a U.S. Government Accountability Office report released in May.

But hospital system and community leaders alike are increasingly tackling the problem head on. Programs—both hospital-based and community efforts—are operating in more than 2 dozen states, according to a recent preliminary inventory by the Center for Health Care Strategies, a nonprofit health policy center based in Hamilton, N.J. One such approach, developed at Regions Hospital, relies on specialized care plans and is being replicated elsewhere.

Dr. Hilger estimates that more than 60 hospitals have contacted him to discuss the hospital's standardized care templates, including Duke University Hospital, which published data on their own efforts online in April.

By targeting the hospital's 24 highest users, Duke was able to reduce admissions among those patients by at least 50% in both the first 6 and the first 12 months after implementation, according to the findings in the Journal of Hospital Medicine (JHM). These days, the Duke program follows roughly 60 patients and moves quickly to add more if an unusual hospital use pattern emerges, said Noppon Setji, MD, ACP Member, an author of the study.

“Before, some of these patients we ended up tackling had utilization patterns that had been going on for 5 or 10 years,” said Dr. Setji, medical director for Duke University Hospital's hospital medicine program. “We don't allow the issue to fester like it did in the past.”

Flagging frequent users

While the criteria of what constitutes a superutilizer can vary, there are some common diagnoses among this population, including mood disorders, schizophrenia, cancer, sickle cell anemia, congestive heart failure, and chronic obstructive pulmonary disease, among others.

Efforts to better help these high-needs, high-cost patients “are popping up just about everywhere” for a couple of reasons, said Mark V. Williams, MD, FACP, chief transformation and learning officer and chief of the Division of Hospital Medicine for University of Kentucky HealthCare.

Academic medical centers are getting an influx of patients, particularly in states that have expanded Medicaid coverage through the Affordable Care Act, he said. Health care reform also changes the impact of these patients on hospital finances. “Institutions are recognizing that soon they are going to be at risk for a population health-type approach to care delivery,” Dr. Williams said.

Despite persistent stereotypes otherwise, superutilizers are typically insured, according to a study published in 2013 in The Journal of Emergency Medicine, which focused on patients who visited the emergency department of Mount Sinai Hospital in New York 20 or more times in a single year. Of those, 81% were insured, but two-thirds were coping with at least 1 psychosocial challenge, including a psychiatric diagnosis, substance abuse, or homelessness.

To address those psychosocial challenges, a hospital-based program must strive to build connections with outpatient resources and community organizations, said Caitlin Thomas-Henkel, MSW, a senior program officer at the Center for Health Care Strategies. The patient leaving the hospital might not have transportation to the next appointment, or even a regular bed to sleep in, she said.

“The misperception is that if we treat the asthma, then we won't see that individual back in the emergency department,” she said. “But what we're hearing from folks who are on the ground is that those social determinants of health are just as important, if not more important, than the medical pieces.”

Coordinating care

At Regions Hospital, a care plan committee was charged with developing templates to address a few common treatment scenarios, such as those involving behavioral health, narcotic restriction, or dialysis care.

These templates, which can then be tailored to a patient's circumstances, prevent doctors from having to “reinvent the wheel each time,” Dr. Hilger said. The committee's imprint also can reduce litigation-related worries. (The standing committee includes lawyers as well as clinicians.) Once a patient has a care plan, its existence is highlighted with a colored bar across the electronic screen, he said.

The hospitalists are crucial to this process, as they have to recommend a patient to the committee for the potential creation of a plan. This spring the hospital was in the process of adding an ordering step in the electronic medical record to streamline the ordering of a care plan referral during the discharge process, he said.

If the committee decides to create a plan, it helps doctors to provide consistent care no matter who is on shift, particularly when narcotic prescribing is involved, Dr. Hilger said. One potential scenario: A patient is demanding morphine but the care plan advises against intravenous narcotics unless there is an acute problem such as a broken bone.

“Mr. Smith can fire me, but my colleague who comes in is going to follow that same care plan,” Dr. Hilger said. “It's really saved a lot of contentious conversations. It's not personal any more. It's not Dr. Hilger saying, ‘No.’” Rather, it's the voice of the hospital's care plan committee, he said.

Based on Regions data from 114 high-utilizing patients, the combined total of emergency department visits and hospital admissions was 65% lower 2 months after the pilot compared with 2 months prior. Hospital admissions alone dropped from 220 to 72 for that group. Program leaders estimated the cost savings at $1.5 million.

As for that patient with heart disease and severe anxiety, along with a history of narcotic misuse, the hospital's committee hammered out a specialized care plan that was similarly influential.

In the 2 months prior to the plan, the man visited the emergency department 20 times and was admitted twice. During the 2 months afterward, the hospital tracked 7 emergency department visits and no admissions for him, according to data provided by Dr. Hilger.

At Duke, the initiative was focused less on specific diagnoses and more on better addressing the needs of that very narrow swathe of superusers, Dr. Setji said. In the JHM study, the 24 patients targeted accounted for a total of 183 emergency department visits and 145 hospital admissions in the 6 months prior to the use of the care plans. Nearly all, 96%, experienced mental health problems or substance abuse, and 83% reported chronic pain, the study found.

Both Dr. Setji and Dr. Hilger emphasized that their committee's plans don't skimp on relief. “We don't ignore their pain,” Dr. Setji said. But it might be that patients are initially prescribed an oral pain medication rather than the intravenous bolus that they're insisting on, he said.

Another advantage of these care plans, which at Duke are also highlighted prominently in the electronic record, is that they quickly summarize prior treatment and thus provide reassurance and guidance to clinicians about when the patient is sick enough to be admitted, Dr. Setji said. Otherwise, the doctor who first happens to see the patient might not know that some 30 abdominal CT scans have already been ordered in the prior 2 years, he said.

Even though the plans are created by a committee, a single doctor should be designated as the point person for that plan and patient, Dr. Setji said. “These patients have so many medical issues and they are so complex socially that things can change fairly rapidly,” he said. “If no one takes ownership of the care plan, then there's no point person to contact to update this new information.”

That point person, typically a hospitalist, can adjust the care plan as circumstances warrant, and other clinicians can recommend changes to it. “They basically are operating as living breathing documents that change from admission to admission,” said Dr. Setji.

Bridging discharge

One caveat on care plans is that they need to be designed in such a way that a change in treatment protocol won't simply deflect needy patients elsewhere, said Dr. Williams, who coauthored an editorial accompanying the Duke analysis in JHM. For example, a sickle cell patient frustrated that she can no longer get her preferred narcotic may look elsewhere.

“If patients end up simply going to another hospital, then hospital A can say, ‘We solved our problem.’” Dr. Williams said. “The patient is still using a lot of services, but going to other facilities.”

To be effective, hospital-based programs also must work hard to figure out the root psychosocial influences of what might seem at first glance to be non-compliance, Dr. Williams said. For example, a patient might not show up regularly for dialysis because he lives in a crime-ridden neighborhood and is fearful of leaving his apartment.

Thus patients' input must be incorporated into not only their individual plans but also these broader efforts targeting superutilizers, according to Dr. Williams. “Patients are experts in the care of themselves,” he said. “So you need to talk with them about what is going to work for them versus ‘This is what you need to do.’ This is the transition from a paternalistic approach to a partnership.”

Clinicians at Duke have made an effort to build outpatient relationships, Dr. Setji said, such as with a pain management clinic that teaches mental health strategies, including biofeedback. They also work with Duke's sickle cell clinic, local representatives for the homeless, and programs that provide home services.

But some patients appear nearly impossible to reach despite fierce efforts, said Dr. Setji, pointing to 1 patient in the initial group of 24. To try to prevent him from using the hospital for urgent dialysis, they set up regular transportation but didn't have much success.

“We offered him everything possible, but he still would not engage,” Dr. Setji said. “Honestly, I think he preferred the culture of the emergency room.”