An Intervention to Improve Care and Reduce Costs for High-Risk Patients with Frequent Hospital Admissions: A Pilot Study

Raven MC, Doran KM, Kostrowski S, Gillespie CC, Elbel BD
Source: BMC Health Serv Res
Publication Year: 2011
Patient Need Addressed: Behavioral health, Care Coordination/Management, Homelessness/housing, Substance Use, Transportation
Population Focus: Complex care, Medicaid beneficiaries
Demographic Group: Adult, Urban
Intervention Type: Best practices, Service redesign, Staff design and care management
Study Design: Pre-post without Comparison Group
Type of Literature: White

BACKGROUND: A small %age of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs.

METHODS: Community and hospital-based care management and coordination intervention with pre-post analysis of healthcare utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach.

RESULTS: Nineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient.

CONCLUSIONS: A pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot’s success can be replicated.

Insights Results

Overview of article/intervention

  • This study focused on piloting a patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs
  • The current study took place at Bellevue Hospital Center (BHC), an 809-bed public hospital in New York City that serves as a “safety net” hospital for a diverse and primarily underserved population, with 500,000 outpatient visits and over 100,000 ED visits yearly
  • This patient-centered intensive care management program was designed to improve care and reduce costly hospital admissions for high risk Medicaid FFS patients
  • 6 key principles guided the intervention: 1) Care must be coordinated and responsive to specific patient needs; 2) Care must not end at hospital discharge, but continue into the community; 3) Medical homes and permanent housing are essential; 4) Integrated, multidisciplinary services and provider teams are necessary to care for the whole patient; 5) Care teams must serve patients where they are, both physically and mentally; and 6) Data sharing and adequate communication among team members is essential for care coordination and tracking patients’ progress
  • The intervention began at the patient’s bedside during the enrollment hospitalization. Patients underwent in-depth interviews to identify immediate and long-term needs such as housing, primary care, transportation to and advocacy during appointments, medication management, entitlements enrollment, improved connections to psychiatric and substance use treatment, and home visits. Study staff worked closely with inpatient providers to facilitate appropriate discharge planning and follow-up
  • To ensure care extended beyond the hospital and addressed complex social needs, a community-based care manager was included to help management and coordination in and outside of the hospital. The manager facilitated transportation to appointments, assisted with entitlements enrollment, conducted home visits, and connected patients to other needed medical and nonmedical services. Pre-paid cellular phones were provided to patients to allow close contact with study staff for reminder calls and crisis management. Patients were provided with expedited medical appointments through cooperation with the BHC outpatient clinics, and Care Managers would accompany patients and advocate for them during appointments when necessary
  • The key to the intervention was close communication with various service providers relevant to the patients in the community

    Methods of article

    • Community and hospital-based care management and coordination intervention with pre-post analysis of healthcare utilization
    • All enrolled participants were men, and nearly all were active substance users and were homeless or marginally housed
    • Patients were interviewed at study enrollment to obtain demographic, health status, and behavioral health information. Although this study was designed primarily to test intervention feasibility, authors also collected objective measures of pilot effectiveness from our hospital’s administrative database, including numbers of hospitalizations, ED visits, and clinic visits, and examined Medicaid billing and reimbursement data for every patient admission and visit to the clinics or ED. Care managers were asked to track all contacts with project participants to analyze staff time allocations and activities
    • Care managers and direct patient services staff employed by the community housing partner, Common Ground Community, participated in a focus group led by research staff trained in qualitative methods


    • Patients received a substantial amount of care management time, on average 11 hours per month
    • Interviews with care managers and staff revealed a number of findings: 1) Need for relatively low patient to care manager ratios given large commitment required per patient; 2) Need to balance assisting patients with encouraging personal responsibilities; 3)Difficulty of changing patients’ long-standing behaviors; and 4) Importance of addressing mental health
    • Most (11 of 15, 73.3%) patients had fewer inpatient admissions in the 12 months after the intervention started compared with the previous 12 months. The minority (4 of 15, 26.7%) had more hospital admissions after the intervention. The annual number of ED visits per patient was decreased by a mean of 0.7 visits, which was not statistically significant. Outpatient clinic use varied by patient, with a statistically significant post-intervention increase of 7.2 visits per patient
    • The decrease in inpatient hospital admissions after study enrollment resulted in a yearly per patient Medicaid cost reduction of $16,588. The decrease in ED visits resulted in a $269 annual per patient reduction in Medicaid reimbursements, whereas the increased outpatient clinic use after the intervention resulted in an increase in per patient yearly Medicaid reimbursements of $474
    • The program resulted in a net reduction in Medicaid spending of $76,194

    Key takeaways/implications

    • Overall, the pilot reduced overall inpatient hospitalizations and emergency department visits, reduced Medicaid reimbursements and overall Medicaid spending
    • There are 3 core guiding principles necessary for working effectively with high risk patients: flexibility, advocacy and partnership
    • Important features of the pilot include the use of pre-paid cell phones to help patients stay in contact with staff, and use of a previously validated case-finding algorithm to identify the most at-risk patients
    • Limitations to the study include small sample size only inclusive of men who speak English or Spanish, inability to track study patients’ visits to other hospitals, non-inclusion of pharmacy costs in evaluation, strictly economic evaluation of costs, and lack of inclusion of all community costs necessary to achieve this intervention
    • The study results are being used to expand the program across additional hospitals via New York State Department of Health-sponsored Chronic Illness Demonstration Project