Hardin Lauran, Kilian Adam, Muller Leslie, Callison Kevin, Olgren Michael
Trinity Health-Michigan dba Mercy Health Saint Mary's, Grand Rapids, Michigan; National Center for Complex Health and Social Needs, Camden, New Jersey.
Trinity Health-Michigan dba Mercy Health Saint Mary's, Grand Rapids, Michigan; University of Utah Health Care, Department of Internal Medicine, Salt Lake City, Utah.
West J Emerg Med. 2017 Feb;18(2):189-200. doi: 10.5811/westjem.2016.11.31916. Epub 2016 Dec 9.
High-need, high-cost (HNHC) patients can over-use acute care services, a pattern of behavior associated with many poor outcomes that disproportionately contributes to increased U.S. healthcare cost. Our objective was to reduce healthcare cost and improve outcomes by optimizing the system of care. We targeted HNHC patients and identified root causes of frequent healthcare utilization. We developed a cross-continuum intervention process and a succinct tool called a Complex Care Map (CCM)© that addresses fragmentation in the system and links providers to a comprehensive individualized analysis of the patient story and causes for frequent access to health services.
Using a pre-/post-test design in which each subject served as his/her own historical control, this quality improvement project focused on determining if the interdisciplinary intervention called CCM© had an impact on healthcare utilization and costs for HNHC patients. We conducted the analysis between November 2012 and December 2015 at Mercy Health Saint Mary's, a Midwestern urban hospital with greater than 80,000 annual emergency department (ED) visits. All referred patients with three or more hospital visits (ED or inpatient [IP]) in the 12 months prior to initiation of a CCM© (n=339) were included in the study. Individualized CCMs© were created and made available in the electronic medical record (EMR) to all healthcare providers. We compared utilization, cost, social, and healthcare access variables from the EMR and cost-accounting system for 12 months before and after CCMs© implementation. We used both descriptive and limited inferential statistics.
ED mean visits decreased 43% (p<0.001), inpatient mean admissions decreased 44% (p<0.001), outpatient mean visits decreased 17% (p<0.001), computed tomography mean scans decreased 62% (p<0.001), and OBS/IP length of stay mean days decreased 41% (p<0.001). Gross charges decreased 45% (p<0.001), direct expenses decreased 47% (p<0.001), contribution margin improved by 11% (p=0.002), and operating margin improved by 73% (p<0.001). Patients with housing increased 14% (p<0.001), those with primary care increased 15% (p<0.001), and those with insurance increased 16% (p<0.001).
Individualized CCMs© for a select group of patients are associated with decreased healthcare system overutilization and cost of care.
高需求、高成本（HNHC）患者可能过度使用急性护理服务，这种行为模式与许多不良后果相关，对美国医疗成本的增加造成了不成比例的影响。我们的目标是通过优化护理系统来降低医疗成本并改善治疗效果。我们将HNHC患者作为目标群体，并确定了频繁使用医疗服务的根本原因。我们开发了一个跨连续护理阶段的干预流程以及一种名为复杂护理地图（CCM）©的简洁工具，该工具可解决系统中的碎片化问题，并将医疗服务提供者与对患者情况及频繁就医原因的全面个性化分析相联系。
本质量改进项目采用前后测试设计，即每个受试者作为其自身的历史对照，重点在于确定名为CCM©的跨学科干预措施是否对HNHC患者的医疗服务利用情况和成本产生影响。我们于2012年11月至2015年12月在梅西健康圣玛丽医院进行了分析，这是一家位于中西部的城市医院，每年急诊科就诊人数超过80,000人次。所有在启动CCM©之前的12个月内有三次或更多次医院就诊（急诊科或住院部[IP]）的转诊患者（n = 339）均纳入研究。为所有医疗服务提供者创建了个性化的CCM©并将其提供在电子病历（EMR）中。我们比较了CCM©实施前后12个月内来自EMR和成本核算系统的利用情况、成本、社会及医疗服务可及性变量。我们使用了描述性统计和有限的推断性统计。
急诊科平均就诊次数减少了43%（p < 0.001），住院部平均入院次数减少了44%（p < 0.001），门诊平均就诊次数减少了17%（p < 0.001），计算机断层扫描平均扫描次数减少了62%（p < 0.001），观察/住院部住院时间平均天数减少了41%（p < 0.001）。总费用减少了45%（p < 0.001），直接费用减少了47%（p < 0.001），边际贡献率提高了11%（p = 0.002），营业利润率提高了73%（p < 0.001）。有住房的患者增加了14%（p < 0.001），有初级护理的患者增加了15%（p < 0.001），有保险的患者增加了16%（p < 0.001）。
为特定患者群体提供的个性化CCM©与医疗系统过度使用的减少及护理成本的降低相关。
