Longitudinal Effects of Integrated Inpatient/Outpatient Care for Patients at Increased Risk of Hospitalization

Longitudinal Effects of Integrated Inpatient/Outpatient Care for Patients at Increased Risk of Hospitalization

PI: David Meltzer, Department of Medicine (Hospital Medicine)

Dates: 7/01/2013 – 06/30/2018
Funder: The Donaghue Foundation

Description: Health care costs and adverse health outcomes are concentrated in a small fraction of the population at increased risk of hospitalization. Hospitalized patients often experience discontinuities between inpatient and outpatient care that increase costs and impair outcomes. This has been especially true as hospitalists have increasingly provided hospital care instead of traditional primary care physicians, who no longer typically have enough patients in the hospital to make it economically viable for them to see hospitalized patients.

With funding from the Center for Medicare and Medicaid Innovation since 2012, we have recruited 2,000 patients for a randomized trial to test whether Medicare patients at increased risk of hospitalization experience better outcomes if they can receive inpatient and outpatient care from the same physician. We make this possible by having a group of comprehensive care physicians (CCPs) who care for a small panel of patients at increased risk of hospitalization so that they have enough patients in the hospital each morning to justify their daily presence there while having a small enough panel of patients that they can provide them with primary care despite only having clinic in the afternoons.

Our preliminary results suggest substantially improved care experience, outcomes, and costs with CCP care over 18-months, but require longer follow-up. The goal of the requested support is to perform long-term followup to assess whether outcomes improve and total resource use declines over 4 years if patients receive inpatient and outpatient care from a CCP compared to different inpatient and outpatient physicians.