Margaret Chapman, M.D.
Bruce Henschen, M.D.
High-Utilizer Patients, Continuity, Care Models, Care Complexity, Case Management, Clinical Research, Hospital Readmissions
Patients who are high-utilizers of hospital resources pose unique challenges to medical and psychosocial support networks that our current fragmented health care delivery model is unable to manage. New systems of care are required to meet the needs of this patient population. The Complex High Admission Management Program (CHAMP), developed at Northwestern Memorial Hospital beginning in 2015, is a longitudinal, relationship-based care model that consists of two social workers (comprised of 1.5 FTE total), two physicians (0.5 FTE), and a program administrator (0.1 FTE). Patients who accrue three or more 30-day inpatient readmissions in a year are eligible for the program. The EMR alerts providers to CHAMP patients; the CHAMP team provides consistency and coordination in care services across the continuum, develops individualized care plans in collaboration with the patient, acts as a hospital consultation service for their patients when admitted, and provides primary care when patients are discharged. Intensive case management and trust building, both with patients and providers, play key roles in identifying and targeting the root causes of high utilization. To analyze the program’s preliminary impact, we have examined rates of hospital admission among patients enrolled in CHAMP compared to retrospective data prior to enrollment. To date, 68 patients have been enrolled; the spectrum of medical and social issues managed is diverse. Patients enrolled in CHAMP experienced a 29.5% decrease in 30-day unplanned readmissions as defined by Medicare (p=0.008), compared with an equal time prior to each patient’s enrollment. There was also a 23% decrease in total inpatient hospital admissions and a 17% decrease in total number of inpatient bed-days following enrollment in the program. Patients self-identified with the CHAMP intervention, and providers from varied settings anecdotally reported improvements in care coordination. Key drivers of success have been re-establishing trust and strengthening engagement in both patients and providers. The program is feasible with institutional support and has been promoted by clinicians and other members of health care teams, administrators, and hospital executives. Further investigations assessing a broader range of outcomes are necessary; a randomized, controlled trial is ongoing to prospectively gather utilization, patient satisfaction and quality of life, and other clinical endpoints.