Reducing High Utilization Patient Care through Improved Provider Communication

Nearly one-fifth of Medicare patients who have been discharged from a hospital in the United States are readmitted within thirty days. Almost half of these hospital readmissions are deemed to be preventable (Verhaegh, K. et. al., 2014). The Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in effort to reduce unnecessary and costly hospital readmissions as they are associated with negative patient outcomes and increased healthcare costs. Transition Programs were developed to work with patients that have complex medical needs placing them at risk for high utilization of acute care services and hospital readmissions. A retrospective review was completed to assess medical care for patients enrolled in the Intermountain Healthcare Utah Valley Integrated Community Care Management Pilot Program to evaluate medical care received. A transitional checklist was created ensure proper management of health needs for this complex patient population as they transition from the acute care setting back into the community. It was identified that a high percentage of patients at risk for high utilization services have mental health service needs. The checklist can be a valuable tool to assess and coordinate these and other community services. More research is needed to better understand the correlation of mental health diagnoses and high utilization of healthcare services.