Intervening With and Improving Care for Patients at Risk for Frequent Hospital Admissions
Condition: Hospitalization; Patient Readmission
Study type: Interventional
Phase: Phase 1

Summary: 
      Patients with frequent hospital admissions account for a disproportionate share of visits and
      costs. An intervention that can bridge the gap between hospital and community based care for
      a population of patients with frequent hospital admissions may offer both improved care and
      cost savings if hospital admissions can be appropriately reduced. We are now using data from
      our previous research to inform the development and implementation of an intervention at
      Bellevue Hospital, which will bridge the gap between hospital and community based care for a
      population of patients with frequent hospital admissions.

      We hypothesize that such an intervention can offer both improved care and cost savings if
      hospital admissions can be appropriately reduced.

      In this protocol we outline a strategy to pilot a small-scale intervention on a small subset
      of patients admitted to an urban public tertiary care safety net hospital who are defined by
      our study criteria as at high risk for future readmission. By piloting components of the
      intervention, we aim to assure the intervention functions as planned, and can deliver the
      needed services to high risk patients in a seamless and patient-centered manner. The purpose
      of this "feasibility study" is to ensure that when our intervention is implemented on a
      larger scale, it appropriately serves enrolled patients needs, and that we are able to
      effectively follow patients during the intervention period.
    

Detailed description: 
      In pilot research, we found that high users at Bellevue Hospital Center had varied
      indications for admission to the hospital, but also shared many risk factors that have been
      traditionally difficult for the health care system to address, including homelessness, social
      isolation, substance use, depression and anxiety, and fragmented primary care. Coordination
      of the multiple service types required to improve care for such patients across hospitals,
      clinics, and community-based organizations is hindered by financial disincentives,
      restrictive funding streams, and poor communication among service providers Intervention
      model and team: The pilot intervention will begin at the patient's bedside in the hospital
      and continue after his/her discharge into the community, utilizing a flexible and intensive
      care management model with a multi-disciplinary team approach. Community Based Care Managers
      (CBCMs) overseen by a social worker, will connect patients to needed community services
      including housing for homeless patients, accompany patients to appointments and facilitate
      transportation to medical, benefits enrollment, and perform other services based in the
      hospital and community.

      So that the intervention can address the multitude of complex medical and social needs of
      high risk patients, in addition to our community partners that address the needs of homeless
      patients, we will partner with additional community providers of mental health, substance
      use, and home medical services who will assist our intervention team staff in managing
      patients' care after hospital discharge. In addition, we will build upon existing specialized
      health and social services within Bellevue Hospital (e.g. provision of prompt outpatient
      clinic appointments) so that this population is better and more effectively served.

      Specific Aims

      1) evaluate the patient and provider experience with various potential components of a pilot
      intervention plan for high risk, high cost patients, (identified using a predictive
      case-finding algorithm) conducted in partnership with community providers of homeless, mental
      health, substance use, and other key services, and 2) evaluate the feasibility of several
      aspects of the intervention. By piloting and evaluating components of the intervention, we
      aim to assure the intervention functions as planned, and can deliver the needed services to
      high risk patients.

      Outcomes:

      Ability of intervention team to:

        1. Function effectively (e.g. communicate and coordinate with one another and with other
           departments in the hospital)

        2. Match patients to appropriate services

        3. Obtain supportive housing for homeless patients with Common Ground partner

        4. Maintain contact with patients after initial hospital discharge

        5. Facilitate patient adherence to outpatient appointments

        6. Link patients with no usual source of care to PMD
    

Intervention name(s): Provision of extra (care coordination and management) services
Intervention type(s): Other
Intervention description(s): The pilot intervention begins at the patient's bedside in the hospital and continue after his/her discharge into the community, utilizing a flexible and intensive care management model with a multi-disciplinary team approach. Community Based Care Managers (CBCMs) overseen by a social worker, will connect patients to needed community services including housing for homeless patients, accompany patients to appointments and facilitate transportation to medical, benefits enrollment, and perform other services based in the hospital and community.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: homelessness; substance use; frequent hospitalization; frequent users of health services; enhanced care management; coordination services p; high risk for frequent hospitalization