126 patient encounters were evaluated. The most frequent Drivers of Utilization were Chronic Unstable Baseline, Unaddressed/Inadequately Managed Behavioral Health, and Unaddressed Goals of Care. Most frequent action items: medication reconciliation and subspecialist follow-up. Next steps: Create a process to evaluate the relationship between action item completion and readmission. Multi-visit patients are those with four or more inpatient admissions within a rolling 12-month period, and they account for a high percentage of hospital readmissions. These patients are complex, with medical, behavioral, and social needs that have been under-addressed. This session describes a process for identifying these patients’ driver(s) of utilization with subsequent action item strategies to better address individual needs and thus reduce readmissions.
Problem: Multi-visit patients are those with four or more inpatient admissions within a rolling 12-month period. These patients are complex, with medical, behavioral, and social needs that have been under-addressed, which results in a cycle of readmission, accounting for a high percentage of hospital 30-day readmissions
Measurement: A driver diagram was used to identify factors that contribute to unmet patient needs. Other tools: multidisciplinary monthly case reviews, brainstorming to categorize patients into one or more of nine Drivers of Utilization from which actionable care coordination tasks are created and assigned to the best-suited team member for completion
Analysis: Data were collected from a subset of all multi-visit patients to quantify patient characteristics, readmission rates, and the frequency of identified Driver(s) of Utilization, and to further summarize the actionable care coordination tasks
Implementation: A multidisciplinary team performs monthly case reviews and identifies each patient’s Driver(s) of Utilization and subsequent actionable tasks. To facilitate a more thorough review, two medical students now prepare each case in advance of the presentation. Microsoft Teams platform was implemented to assign and better track follow-up action items.