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Transforming Care for High Needs Patients Cheat Sheet (DRAFT) by [deleted]

Transforming Care for High Needs Patients

This is a draft cheat sheet. It is a work in progress and is not finished yet.


The top 5 percent of spenders account for nearly 60 percent of total health costs, and people with multiple chronic conditions account for 93 percent of total Medicare spending. When the burden of serious illness exceeds a person’s or family’s capacity, the recourse is usually a visit to the hospital emergency depart­ment. 

There are ways hospitals can respond to the explosion of older adults living with chronic condit­ions. With these strate­gies, hospitals will be providing quality, high-value value care that results in less suffering for patients.

Here are five recomm­end­ations for how hospitals and health systems can address this challenge:

Recomm­end­ations 1 -2

1. Identify the high-need group. To match services to needs, identify the high-need group through systemwide screening. Patients with one or more serious illnesses plus a hospit­ali­zation or skilled nursing facility admission in the prior 12 months plus functional dependency have a 50 percent likelihood to be hospit­alized in the next 12 months. These data points, except functional depend­ency, are available to hospital leader­ship. Requiring docume­ntation of function in your electronic health record using a drop-down menu will address this gap.

2. Assess and risk-s­tratify the high-need group. The most common reason for after-­hours 911 calls is symptoms, e.g., out-of­-co­ntrol pain, shortness of breath, agitation or exhaus­tion. Use EHR data to identify these precip­itants. If the dominant root cause of revolv­ing­-door ED visits and hospit­ali­zation is recurrent pain or shortness of breath, bring in clinicians with palliative care expertise.

Strati­fic­ation of Care

Recomm­end­ations 3 - 5

3. Match services to needs. Social work support is the right interv­ention for homeless indivi­duals who return frequently to the ED. But in most cases of serious medical illness, frequent reliance on acute care is due to disease progre­ssion, increased suffering and worsening functional decline. The best approach in these cases is palliative care, available in more than 65 percent of U.S. hospitals with more than 50 beds. Ensuring adequate staffing and capacity to serve this growing, complex patient population is critical.

4. Train your workforce. Most physicians and nurses lack training in the core knowledge and skills of palliative care, including commun­icating prognoses, establ­ishing care priori­ties, conducting family meetings, coordi­nating care across settings, and safely and effect­ively managing pain and other symptoms. High-q­uality, online training on these skills is widely available and afford­able.

5. Track outcomes. To determine if initia­tives are improving care, track outcomes like 30-day readmi­ssions, hospital mortality and root causes of ED use. Place respon­sib­ility for these outcomes on leadership dashbo­ards.