An initial case study of a readmission and emergency department revisit reduction program for high utilizer patients at a large community hospital system in Massachusetts
Wier Guilhardi, Lauren Michelle
MetadataShow full item record
BACKGROUND: This dissertation presents an initial, mixed-methods case study of a hospital-based multidisciplinary care team (MCT) program designed to reduce hospital readmissions and emergency department (ED) revisits among patients with high hospital utilization without restrictions in a large, not-for-profit, non-teaching, community hospital system. METHODS: High utilizers were defined by either ≥10 ED visits or ≥4 inpatient stays within the past 12 months on a rolling basis. Electronic medical records and retrospective patient-level surveys completed by MCT staff provided insight into program reach and implementation, as well as initial impacts on hospital-based outcomes, non-hospital based outcomes, and staff-perceived impacts of MCT services on patients. Interviews with MCT patients, program staff, hospital administrators, community partners, and field experts were analyzed to understand the key challenges, best practices, and lessons learned to help inform transferability and sustainability of this type of program. RESULTS: Of the 1,680 patients who were identified as eligible high utilizers, about half received ≥2 telephone calls or face-to-face visits with the MCT. There were significant delays to patients receiving MCT services, especially for patients who met eligibility criteria within the first few months of the program initiation. Data reflected the high number of MCT encounters and breadth of services provided to MCT participants. On average, changes in post-period ED revisit and inpatient readmission rates were not significantly different from pre-period rates for MCT participants overall, or when broken down by initial classification as an inpatient or ED high utilizer. MCT staff reported improvements in housing stability, usual source of care, and substance use treatment or recovery for MCT participants. Staff perceived positive overall and specific impacts of MCT services for a large portion of patients, with greater perceived positive impacts on all outcomes with increasing program duration. Salient themes from the qualitative data analysis included the heterogeneity of the high utilizer population, internal communication and support, community integration, and financing. CONCLUSION: This initial study, conducted prior to the conclusion of the full MCT program, provided insight into the strengths, challenges, and early lessons learned from a hospital-based multidisciplinary care team program designed to reduce high readmission and revisit rates among high utilizers. This study also lays the groundwork for a full post-program evaluation in the future.