Individualized Care Plans for High Utilizers

Frequently admitted patients (i.e., ‘high utilizers’) comprise a small percentage of all patients yet consume a relatively large proportion of hospital resources. This quality improvement project aimed to reduce hospital resource utilization by implementing individualized care plans (ICPs) for high utilizers. An electronic health record (EHR) report identified high utilizers. A hospitalist workgroup then selected patients who were relatively young with frequent low-risk admissions. The workgroup created and documented ICPs in the EHR, then linked to the ICPs from numerous locations. For the selected patients, total admissions per year were reduced from 125 to 41 (-67%) and days per year in hospital from 497 to 219 (-56%), while length of stay was increased from 4 to 5.4 (+26%) days. Implementation of ICPs can allow high utilizers to spend more time at home, while simultaneously freeing up valuable hospital resources for the community. Making ICPs easily accessible is key to success.