Individualized Care Plans

High utilizers of hospital services are medically complex, psychosocially vulnerable, and at risk for adverse health outcomes.[1, 2] They make up a fraction of the patient population but use a disproportionate amount of resources, with high rates of emergency department (ED) visits and hospital admissions.[1, 3, 4] Less than 1% of patients account for 21% of national healthcare spending, and hospital costs are the largest category of national healthcare expenditures.[2, 5] Many patients who disproportionately contribute to high healthcare costs also have high hospital admission rates.[6]

Interventions targeting high utilizers have typically focused on the outpatient setting.[7, 8, 9, 10] Interventions using individualized care plans in the ED reduced ED visits from 33% to 70%, but all have required an additional case management program or partnership with an outside nonprofit case management organization.[11, 12, 13] One study by a hospitalist group using individualized care plans reduced ED visits and admissions by 70%, 2 months after care‐plan implementation; however, all of their care plans were focused explicitly on restricting intravenous opiate use for patients with chronic pain.[14]

Given the current focus on cost‐conscious, high‐quality care in the American healthcare system, we designed a quality‐improvement (QI) intervention using individualized care plans to reduce unnecessary healthcare service utilization and hospital costs for the highest utilizers of ED and inpatient care. Our approach focuses on integrating care plans within our electronic medical record (EMR) and implementing them using the existing healthcare workforce. We analyzed pre‐ and postintervention data to determine its effect on service utilization and hospital costs across a regional health system.

METHODS

RESULTS

Table 1 shows the demographics and comorbidities for the 24 patients with care plans included in this analysis. The average age of patients is 38.5 years (range, 2565 years) and a nearly even split between males (11) and females (13). Chronic disease burden is high. Furthermore, 83% of patients have chronic pain and 96% have mental health problems or substance abuse.

Table 2 shows inpatient and ED utilization patterns before and after care‐plan implementation. Inpatient admissions decreased by 56% for the 6 months after care‐plan implementation (P<0.001) and by 50.5% for the 12 months after care‐plan implementation (P=0.003). This translates to a decrease in the average number of admissions per patient from 6.3 to 2.4, 6 months postcare plan, and from 10.9 to 4.8, 12 months postcare plan.

Thirty‐day readmissions also significantly decreased after care‐plan implementation. Among the 23 patients with data 6 months pre and postcare plan, there were 130 readmissions before and 44 readmissions after care‐plan implementation, a 66% reduction (P<0.001). Among the 12 patients with data 12 months pre and postcare plan, there were 106 readmissions before and 45 readmissions after care‐plan implementation, a 51.5% reduction (P=0.002). Inpatient LOS did not show a statistically significant change after care‐plan implementation.

ED visits were similar for the 6 months pre compared to 6 months postcare plan. ED visits at 12 months postcare plan increased from an average of 15.4 visits pre to 25.6 visits per patient postcare plan. This was driven by a single homeless patient with dialysis‐dependent end‐stage renal disease, who had 134 ED visits in the 12 months after careplan implementation. Analysis of the data with this outlier removed showed a reduction in ED visits from an average of 12.3 visits per patient to 10.1 visits per patient in the 12 months postcare plan; however, this was not statistically significant (P=0.66, data not shown).

Table 3 shows inpatient and ED VDCs before and after care‐plan implementation. The average VDCs per patient per admission decreased from $29,852.71 to $15,587.84, 6 months after care‐plan implementation, a 47.7% reduction (P=0.001). The average VDCs per patient per admission decreased from $44,881.66 to $24,958.42, 12 months after care‐plan implementation, a 35.8% reduction (P=0.052). ED costs did not show a statistically significant decrease. However, with the outlier removed as above, costs did decrease by 12.3%, 6 months after care‐plan implementation, approaching statistical significance (P=0.073, data not shown). Combined inpatient and ED variable direct costs decreased by an average of $15,117.30, 6 months after care‐plan implementation, a 45.3% reduction (P=0.002), and by an average of $18,604.50, 12 months after care‐plan implementation, a 25.5% reduction, although this did not reach statistical significance (P=0.129).

DISCUSSION

A multidisciplinary team at our academic medical center developed individualized care plans tailored to the specific medical and psychosocial complexities of high utilizers to reduce unnecessary service utilization and hospital costs. Postintervention analysis shows reduced inpatient admissions and 30‐day readmissions among this population by 50%. Furthermore, inpatient variable direct costs decreased by 47% for the 6 months following care‐plan implementation and by 35% for the 12 months following care‐plan implementation. This translates into a $347,696.97 cost savings for the 23 patients 6 months after care‐plan implementation, and a $223,253.89 cost savings for the 12 patients 12 months after care‐plan implementation. This reduction in utilization and cost was seen across all 3 hospitals in the Duke University Health System, including the only 2 hospitals in Durham, North Carolina. Unlike other urban areas, public transportation in our region is scarce, and the options for hospital shopping in central North Carolina are relatively limited. Although this study does not measure utilization in surrounding counties, we do not feel this occurred as we did not see a rise in requests for medical records nor attempts to contact Duke providers for questions on these patients as a result of our intervention. This, along with our regional health system outcome analysis, provides support that our intervention did not cause patients to seek care elsewhere and result in cost‐shifting to other facilities.

We hypothesize that our care plans may be responsible for decreased admissions and 30‐day readmissions through several mechanisms. By raising awareness of these patients' excessive hospital utilization patterns and making this information readily available through our EMR, providers in the ED may be more conscientious about their admission decisions. Problems that at face value seem acute, are often more chronic and can be better managed in the outpatient setting. Several care plans also explicitly recommend limiting unnecessary intravenous opiate use for chronic pain patients. Other patients who have frequent admissions actually have end‐stage disease, and care plans for these patients help facilitate referrals to hospice programs.

Care plans provide a consistent message of patient histories, utilization patterns, and management strategies, and also serve as a communication tool between hospitalists and ED providers. A systematic review of all ED‐based interventions for high utilizers revealed that most studies did show a reduction in ED visits, but all incorporated case management programs to do so.[15] We did not reduce ED visits, possibly because we lacked the resources and care coordination a community‐based case management program provides. However, care plans did serve as a platform with which hospitalists and ED providers can help coordinate care among multiple outpatient providers. This has potentially limited admissions by providing a referral destination or outpatient point of contact for ED providers. For example, as a result of our intervention, referral mechanisms to our comprehensive pain clinic and outpatient psychiatry clinic have both been strengthened and streamlined. The fact that care plans decreased admissions and readmissions, but not ED visits, suggests that our intervention may not have actually changed patient behavior, but instead changed provider practices in relation to disposition decisions in the ED.

Our QI intervention has several strengths. First, it is fully integrated within our existing healthcare workforce, without the need for an extra case management system. Second, it is seamlessly incorporated into our EMR and represents another potential use of an EMR that has not been previously touted. Third, the multidisciplinary nature of the CCPC ensures that all stakeholders involved in the care of high utilizers are represented. Fourth, the outcome analysis across all 3 hospitals in our health system provides a balancing metric against the notion that our intervention simply caused patients to seek care elsewhere in the region. Last, the QI design and lack of strict inclusion and exclusion criteria adds practicality and shows effectiveness, not just efficacy, of the intervention.

Because this was developed as a QI intervention without strict inclusion and exclusion criteria, generalizability is lacking. In the future, one could use the EMR to more systematically identify high‐utilizing, complex patients. One study showed the ability to use the EMR with a standardized framework to identify hot spotting (high utilizers) and contextual anomaly detection (ie, anomalous utilization cases where patient‐incurred levels of utilization are unexpected given their clinical characteristics).[16] The nonrandomized, retrospective pre/post‐intervention analysis without a control group diminishes the external validity of the results and does introduce the potential for bias.

One of the primary study limitations includes the small sample size of only 24 patients. Admittedly, these first 24 patients are the absolute highest utilizers of care at our hospital, possibly making their utilization patterns more amenable to our intervention. The 96% prevalence rate of mental health and substance abuse in our cohort is significantly higher than other published data among high utilizers.[4, 17, 18] We are continuing to develop care plans for additional high‐utilizing, complex patients, and expect to enroll more patients with end‐stage disease, and relatively fewer with substance abuse or psychiatric illness as time goes on. It is possible this new cohort of patients has proportionally less unnecessary utilization, thus limiting our intervention effect. One final limitation of our study is the lack of care quality and patient safety outcomes. In future studies, health outcomes, adverse events, and outpatient care utilization will be important balancing measures to include.

In conclusion, we showed that a QI intervention using individualized care plans reduces hospital admissions, 30‐day readmissions, and hospital costs across a regional health system for a group of complex, high‐utilizing patients. This intervention can, and should, be developed by a multidisciplinary team and fully integrated into the existing healthcare workforce and EMR to ensure appropriateness, effectiveness, and longevity. Going forward, it will be imperative to evaluate this intervention prospectively, at multiple sites, in coordination with outpatient providers, and including quality and safety outcomes to determine if this hospital‐based intervention impacts care coordination, utilization rates, cost, and health outcomes across the broader healthcare system.

High utilizers of hospital services are medically complex, psychosocially vulnerable, and at risk for adverse health outcomes.[1, 2] They make up a fraction of the patient population but use a disproportionate amount of resources, with high rates of emergency department (ED) visits and hospital admissions.[1, 3, 4] Less than 1% of patients account for 21% of national healthcare spending, and hospital costs are the largest category of national healthcare expenditures.[2, 5] Many patients who disproportionately contribute to high healthcare costs also have high hospital admission rates.[6]

Interventions targeting high utilizers have typically focused on the outpatient setting.[7, 8, 9, 10] Interventions using individualized care plans in the ED reduced ED visits from 33% to 70%, but all have required an additional case management program or partnership with an outside nonprofit case management organization.[11, 12, 13] One study by a hospitalist group using individualized care plans reduced ED visits and admissions by 70%, 2 months after care‐plan implementation; however, all of their care plans were focused explicitly on restricting intravenous opiate use for patients with chronic pain.[14]

Given the current focus on cost‐conscious, high‐quality care in the American healthcare system, we designed a quality‐improvement (QI) intervention using individualized care plans to reduce unnecessary healthcare service utilization and hospital costs for the highest utilizers of ED and inpatient care. Our approach focuses on integrating care plans within our electronic medical record (EMR) and implementing them using the existing healthcare workforce. We analyzed pre‐ and postintervention data to determine its effect on service utilization and hospital costs across a regional health system.

METHODS

RESULTS

Table 1 shows the demographics and comorbidities for the 24 patients with care plans included in this analysis. The average age of patients is 38.5 years (range, 2565 years) and a nearly even split between males (11) and females (13). Chronic disease burden is high. Furthermore, 83% of patients have chronic pain and 96% have mental health problems or substance abuse.

Table 2 shows inpatient and ED utilization patterns before and after care‐plan implementation. Inpatient admissions decreased by 56% for the 6 months after care‐plan implementation (P<0.001) and by 50.5% for the 12 months after care‐plan implementation (P=0.003). This translates to a decrease in the average number of admissions per patient from 6.3 to 2.4, 6 months postcare plan, and from 10.9 to 4.8, 12 months postcare plan.

Thirty‐day readmissions also significantly decreased after care‐plan implementation. Among the 23 patients with data 6 months pre and postcare plan, there were 130 readmissions before and 44 readmissions after care‐plan implementation, a 66% reduction (P<0.001). Among the 12 patients with data 12 months pre and postcare plan, there were 106 readmissions before and 45 readmissions after care‐plan implementation, a 51.5% reduction (P=0.002). Inpatient LOS did not show a statistically significant change after care‐plan implementation.

ED visits were similar for the 6 months pre compared to 6 months postcare plan. ED visits at 12 months postcare plan increased from an average of 15.4 visits pre to 25.6 visits per patient postcare plan. This was driven by a single homeless patient with dialysis‐dependent end‐stage renal disease, who had 134 ED visits in the 12 months after careplan implementation. Analysis of the data with this outlier removed showed a reduction in ED visits from an average of 12.3 visits per patient to 10.1 visits per patient in the 12 months postcare plan; however, this was not statistically significant (P=0.66, data not shown).

Table 3 shows inpatient and ED VDCs before and after care‐plan implementation. The average VDCs per patient per admission decreased from $29,852.71 to $15,587.84, 6 months after care‐plan implementation, a 47.7% reduction (P=0.001). The average VDCs per patient per admission decreased from $44,881.66 to $24,958.42, 12 months after care‐plan implementation, a 35.8% reduction (P=0.052). ED costs did not show a statistically significant decrease. However, with the outlier removed as above, costs did decrease by 12.3%, 6 months after care‐plan implementation, approaching statistical significance (P=0.073, data not shown). Combined inpatient and ED variable direct costs decreased by an average of $15,117.30, 6 months after care‐plan implementation, a 45.3% reduction (P=0.002), and by an average of $18,604.50, 12 months after care‐plan implementation, a 25.5% reduction, although this did not reach statistical significance (P=0.129).

DISCUSSION

A multidisciplinary team at our academic medical center developed individualized care plans tailored to the specific medical and psychosocial complexities of high utilizers to reduce unnecessary service utilization and hospital costs. Postintervention analysis shows reduced inpatient admissions and 30‐day readmissions among this population by 50%. Furthermore, inpatient variable direct costs decreased by 47% for the 6 months following care‐plan implementation and by 35% for the 12 months following care‐plan implementation. This translates into a $347,696.97 cost savings for the 23 patients 6 months after care‐plan implementation, and a $223,253.89 cost savings for the 12 patients 12 months after care‐plan implementation. This reduction in utilization and cost was seen across all 3 hospitals in the Duke University Health System, including the only 2 hospitals in Durham, North Carolina. Unlike other urban areas, public transportation in our region is scarce, and the options for hospital shopping in central North Carolina are relatively limited. Although this study does not measure utilization in surrounding counties, we do not feel this occurred as we did not see a rise in requests for medical records nor attempts to contact Duke providers for questions on these patients as a result of our intervention. This, along with our regional health system outcome analysis, provides support that our intervention did not cause patients to seek care elsewhere and result in cost‐shifting to other facilities.

We hypothesize that our care plans may be responsible for decreased admissions and 30‐day readmissions through several mechanisms. By raising awareness of these patients' excessive hospital utilization patterns and making this information readily available through our EMR, providers in the ED may be more conscientious about their admission decisions. Problems that at face value seem acute, are often more chronic and can be better managed in the outpatient setting. Several care plans also explicitly recommend limiting unnecessary intravenous opiate use for chronic pain patients. Other patients who have frequent admissions actually have end‐stage disease, and care plans for these patients help facilitate referrals to hospice programs.

Care plans provide a consistent message of patient histories, utilization patterns, and management strategies, and also serve as a communication tool between hospitalists and ED providers. A systematic review of all ED‐based interventions for high utilizers revealed that most studies did show a reduction in ED visits, but all incorporated case management programs to do so.[15] We did not reduce ED visits, possibly because we lacked the resources and care coordination a community‐based case management program provides. However, care plans did serve as a platform with which hospitalists and ED providers can help coordinate care among multiple outpatient providers. This has potentially limited admissions by providing a referral destination or outpatient point of contact for ED providers. For example, as a result of our intervention, referral mechanisms to our comprehensive pain clinic and outpatient psychiatry clinic have both been strengthened and streamlined. The fact that care plans decreased admissions and readmissions, but not ED visits, suggests that our intervention may not have actually changed patient behavior, but instead changed provider practices in relation to disposition decisions in the ED.

Our QI intervention has several strengths. First, it is fully integrated within our existing healthcare workforce, without the need for an extra case management system. Second, it is seamlessly incorporated into our EMR and represents another potential use of an EMR that has not been previously touted. Third, the multidisciplinary nature of the CCPC ensures that all stakeholders involved in the care of high utilizers are represented. Fourth, the outcome analysis across all 3 hospitals in our health system provides a balancing metric against the notion that our intervention simply caused patients to seek care elsewhere in the region. Last, the QI design and lack of strict inclusion and exclusion criteria adds practicality and shows effectiveness, not just efficacy, of the intervention.

Because this was developed as a QI intervention without strict inclusion and exclusion criteria, generalizability is lacking. In the future, one could use the EMR to more systematically identify high‐utilizing, complex patients. One study showed the ability to use the EMR with a standardized framework to identify hot spotting (high utilizers) and contextual anomaly detection (ie, anomalous utilization cases where patient‐incurred levels of utilization are unexpected given their clinical characteristics).[16] The nonrandomized, retrospective pre/post‐intervention analysis without a control group diminishes the external validity of the results and does introduce the potential for bias.

One of the primary study limitations includes the small sample size of only 24 patients. Admittedly, these first 24 patients are the absolute highest utilizers of care at our hospital, possibly making their utilization patterns more amenable to our intervention. The 96% prevalence rate of mental health and substance abuse in our cohort is significantly higher than other published data among high utilizers.[4, 17, 18] We are continuing to develop care plans for additional high‐utilizing, complex patients, and expect to enroll more patients with end‐stage disease, and relatively fewer with substance abuse or psychiatric illness as time goes on. It is possible this new cohort of patients has proportionally less unnecessary utilization, thus limiting our intervention effect. One final limitation of our study is the lack of care quality and patient safety outcomes. In future studies, health outcomes, adverse events, and outpatient care utilization will be important balancing measures to include.

In conclusion, we showed that a QI intervention using individualized care plans reduces hospital admissions, 30‐day readmissions, and hospital costs across a regional health system for a group of complex, high‐utilizing patients. This intervention can, and should, be developed by a multidisciplinary team and fully integrated into the existing healthcare workforce and EMR to ensure appropriateness, effectiveness, and longevity. Going forward, it will be imperative to evaluate this intervention prospectively, at multiple sites, in coordination with outpatient providers, and including quality and safety outcomes to determine if this hospital‐based intervention impacts care coordination, utilization rates, cost, and health outcomes across the broader healthcare system.

High utilizers of hospital services are medically complex, psychosocially vulnerable, and at risk for adverse health outcomes.[1, 2] They make up a fraction of the patient population but use a disproportionate amount of resources, with high rates of emergency department (ED) visits and hospital admissions.[1, 3, 4] Less than 1% of patients account for 21% of national healthcare spending, and hospital costs are the largest category of national healthcare expenditures.[2, 5] Many patients who disproportionately contribute to high healthcare costs also have high hospital admission rates.[6]

Interventions targeting high utilizers have typically focused on the outpatient setting.[7, 8, 9, 10] Interventions using individualized care plans in the ED reduced ED visits from 33% to 70%, but all have required an additional case management program or partnership with an outside nonprofit case management organization.[11, 12, 13] One study by a hospitalist group using individualized care plans reduced ED visits and admissions by 70%, 2 months after care‐plan implementation; however, all of their care plans were focused explicitly on restricting intravenous opiate use for patients with chronic pain.[14]

Given the current focus on cost‐conscious, high‐quality care in the American healthcare system, we designed a quality‐improvement (QI) intervention using individualized care plans to reduce unnecessary healthcare service utilization and hospital costs for the highest utilizers of ED and inpatient care. Our approach focuses on integrating care plans within our electronic medical record (EMR) and implementing them using the existing healthcare workforce. We analyzed pre‐ and postintervention data to determine its effect on service utilization and hospital costs across a regional health system.

METHODS

RESULTS

Table 1 shows the demographics and comorbidities for the 24 patients with care plans included in this analysis. The average age of patients is 38.5 years (range, 2565 years) and a nearly even split between males (11) and females (13). Chronic disease burden is high. Furthermore, 83% of patients have chronic pain and 96% have mental health problems or substance abuse.

Table 2 shows inpatient and ED utilization patterns before and after care‐plan implementation. Inpatient admissions decreased by 56% for the 6 months after care‐plan implementation (P<0.001) and by 50.5% for the 12 months after care‐plan implementation (P=0.003). This translates to a decrease in the average number of admissions per patient from 6.3 to 2.4, 6 months postcare plan, and from 10.9 to 4.8, 12 months postcare plan.

Thirty‐day readmissions also significantly decreased after care‐plan implementation. Among the 23 patients with data 6 months pre and postcare plan, there were 130 readmissions before and 44 readmissions after care‐plan implementation, a 66% reduction (P<0.001). Among the 12 patients with data 12 months pre and postcare plan, there were 106 readmissions before and 45 readmissions after care‐plan implementation, a 51.5% reduction (P=0.002). Inpatient LOS did not show a statistically significant change after care‐plan implementation.

ED visits were similar for the 6 months pre compared to 6 months postcare plan. ED visits at 12 months postcare plan increased from an average of 15.4 visits pre to 25.6 visits per patient postcare plan. This was driven by a single homeless patient with dialysis‐dependent end‐stage renal disease, who had 134 ED visits in the 12 months after careplan implementation. Analysis of the data with this outlier removed showed a reduction in ED visits from an average of 12.3 visits per patient to 10.1 visits per patient in the 12 months postcare plan; however, this was not statistically significant (P=0.66, data not shown).

Table 3 shows inpatient and ED VDCs before and after care‐plan implementation. The average VDCs per patient per admission decreased from $29,852.71 to $15,587.84, 6 months after care‐plan implementation, a 47.7% reduction (P=0.001). The average VDCs per patient per admission decreased from $44,881.66 to $24,958.42, 12 months after care‐plan implementation, a 35.8% reduction (P=0.052). ED costs did not show a statistically significant decrease. However, with the outlier removed as above, costs did decrease by 12.3%, 6 months after care‐plan implementation, approaching statistical significance (P=0.073, data not shown). Combined inpatient and ED variable direct costs decreased by an average of $15,117.30, 6 months after care‐plan implementation, a 45.3% reduction (P=0.002), and by an average of $18,604.50, 12 months after care‐plan implementation, a 25.5% reduction, although this did not reach statistical significance (P=0.129).

DISCUSSION

A multidisciplinary team at our academic medical center developed individualized care plans tailored to the specific medical and psychosocial complexities of high utilizers to reduce unnecessary service utilization and hospital costs. Postintervention analysis shows reduced inpatient admissions and 30‐day readmissions among this population by 50%. Furthermore, inpatient variable direct costs decreased by 47% for the 6 months following care‐plan implementation and by 35% for the 12 months following care‐plan implementation. This translates into a $347,696.97 cost savings for the 23 patients 6 months after care‐plan implementation, and a $223,253.89 cost savings for the 12 patients 12 months after care‐plan implementation. This reduction in utilization and cost was seen across all 3 hospitals in the Duke University Health System, including the only 2 hospitals in Durham, North Carolina. Unlike other urban areas, public transportation in our region is scarce, and the options for hospital shopping in central North Carolina are relatively limited. Although this study does not measure utilization in surrounding counties, we do not feel this occurred as we did not see a rise in requests for medical records nor attempts to contact Duke providers for questions on these patients as a result of our intervention. This, along with our regional health system outcome analysis, provides support that our intervention did not cause patients to seek care elsewhere and result in cost‐shifting to other facilities.

We hypothesize that our care plans may be responsible for decreased admissions and 30‐day readmissions through several mechanisms. By raising awareness of these patients' excessive hospital utilization patterns and making this information readily available through our EMR, providers in the ED may be more conscientious about their admission decisions. Problems that at face value seem acute, are often more chronic and can be better managed in the outpatient setting. Several care plans also explicitly recommend limiting unnecessary intravenous opiate use for chronic pain patients. Other patients who have frequent admissions actually have end‐stage disease, and care plans for these patients help facilitate referrals to hospice programs.

Care plans provide a consistent message of patient histories, utilization patterns, and management strategies, and also serve as a communication tool between hospitalists and ED providers. A systematic review of all ED‐based interventions for high utilizers revealed that most studies did show a reduction in ED visits, but all incorporated case management programs to do so.[15] We did not reduce ED visits, possibly because we lacked the resources and care coordination a community‐based case management program provides. However, care plans did serve as a platform with which hospitalists and ED providers can help coordinate care among multiple outpatient providers. This has potentially limited admissions by providing a referral destination or outpatient point of contact for ED providers. For example, as a result of our intervention, referral mechanisms to our comprehensive pain clinic and outpatient psychiatry clinic have both been strengthened and streamlined. The fact that care plans decreased admissions and readmissions, but not ED visits, suggests that our intervention may not have actually changed patient behavior, but instead changed provider practices in relation to disposition decisions in the ED.

Our QI intervention has several strengths. First, it is fully integrated within our existing healthcare workforce, without the need for an extra case management system. Second, it is seamlessly incorporated into our EMR and represents another potential use of an EMR that has not been previously touted. Third, the multidisciplinary nature of the CCPC ensures that all stakeholders involved in the care of high utilizers are represented. Fourth, the outcome analysis across all 3 hospitals in our health system provides a balancing metric against the notion that our intervention simply caused patients to seek care elsewhere in the region. Last, the QI design and lack of strict inclusion and exclusion criteria adds practicality and shows effectiveness, not just efficacy, of the intervention.

Because this was developed as a QI intervention without strict inclusion and exclusion criteria, generalizability is lacking. In the future, one could use the EMR to more systematically identify high‐utilizing, complex patients. One study showed the ability to use the EMR with a standardized framework to identify hot spotting (high utilizers) and contextual anomaly detection (ie, anomalous utilization cases where patient‐incurred levels of utilization are unexpected given their clinical characteristics).[16] The nonrandomized, retrospective pre/post‐intervention analysis without a control group diminishes the external validity of the results and does introduce the potential for bias.

One of the primary study limitations includes the small sample size of only 24 patients. Admittedly, these first 24 patients are the absolute highest utilizers of care at our hospital, possibly making their utilization patterns more amenable to our intervention. The 96% prevalence rate of mental health and substance abuse in our cohort is significantly higher than other published data among high utilizers.[4, 17, 18] We are continuing to develop care plans for additional high‐utilizing, complex patients, and expect to enroll more patients with end‐stage disease, and relatively fewer with substance abuse or psychiatric illness as time goes on. It is possible this new cohort of patients has proportionally less unnecessary utilization, thus limiting our intervention effect. One final limitation of our study is the lack of care quality and patient safety outcomes. In future studies, health outcomes, adverse events, and outpatient care utilization will be important balancing measures to include.

In conclusion, we showed that a QI intervention using individualized care plans reduces hospital admissions, 30‐day readmissions, and hospital costs across a regional health system for a group of complex, high‐utilizing patients. This intervention can, and should, be developed by a multidisciplinary team and fully integrated into the existing healthcare workforce and EMR to ensure appropriateness, effectiveness, and longevity. Going forward, it will be imperative to evaluate this intervention prospectively, at multiple sites, in coordination with outpatient providers, and including quality and safety outcomes to determine if this hospital‐based intervention impacts care coordination, utilization rates, cost, and health outcomes across the broader healthcare system.