REDUCING ER USE THROUGH A TRAINEE-DESIGNED, INTERPROFESSIONAL CARE GROUP FOR HIGH-UTILIZING CHRONICALLY ILL PATIENTS: A PILOT PROGRAM.

BACKGROUND: Healthcare utilization is skewed to a subset of high-need, high-use patients, but optimal models of care are not known.

PURPOSE: To reduce emergency room (ER) use and hospital readmissions, trainees designed an innovative model of care delivery for chronically ill, high-utilizing adult patients.

METHODS: Enrolled patients (N = 65) joined an interprofessional care program (nutrition, behavioral health, pharmacy, and care coordination), located in a single ambulatory clinic with extended hours.

RESULTS: Evaluated by generalized linear mixed-effects models, the primary outcome of all-cause ER visits showed a significant decreasing trend after enrollment, from an increasing odds of ER visits (OR 1.07) in the 12-months prior to the program, compared to a decreasing trend post-enrollment (OR 0.88). Implementation and completion of the program was cost neutral.

DISCUSSION AND CONCLUSIONS: This pilot supports team-based ambulatory care models that address the diverse needs of chronically ill patients, with a focus on improving select health services utilization.