SHM Converge Scientific Abstract ePoster Gallery-Intervenable Care Gaps Identified for Inpatient High Utilizers

Pdf Summary

This quality improvement project at Novant Health–New Hanover Regional Medical Center examined inpatient high utilizers to identify modifiable care gaps and reduce recurrent admissions. Using Plan-Do-Study-Act methodology, a multidisciplinary team reviewed patients with either 10 ED visits or 3 admissions during 2022 and assessed primary care access, advanced care planning, social determinants of health, and frailty.<br /><br />The study identified 872 inpatient high utilizers, with an average age of 64. Frailty was the most common contributing factor, often related to multiple comorbidities, cancer, or recurrent sepsis. Nearly 39% of these patients did not have a primary care provider (PCP), while 48.4% were seen by one of eight major local primary care practices. Only 29.9% had documented advanced care directives. About 14% had frailty or other social determinants of health documented.<br /><br />Mortality was high: 274 patients died during the study year. Among those without a PCP, 34.3% died, compared with 33.4% among those with a PCP. Patients with a PCP averaged four encounters with their provider. The authors highlight access to primary care and palliative care as two major care gaps that may be targeted to improve outcomes for high-utilizer patients.<br /><br />The project underscores the large clinical and financial burden of super-utilizers and suggests that better outpatient continuity, advance care planning, and earlier palliative support may help reduce repeat hospital use and improve care.

Asset Subtitle

Tyler Brazee

Meta Tag

Author List Charin Hanlon, Gabriela Mosquera-Cordero, Stella Ogbonna, Tyler Brazee

Category Research

Concept Inpatient High-Utilizer Patient

Concept PDSA Cycle

Concept Primary Care Provider

Concept Primary Care Access

Concept Quality Improvement

Distinguished Non-Finalist

Presenter Organization Novant New Hanover Regional Medical Center

Presenting Author Tyler Brazee

Track Quality Improvement

Keywords

quality improvement

high utilizers

inpatient admissions

primary care access

advanced care planning

frailty

social determinants of health

palliative care

recurrent admissions

Plan-Do-Study-Act

Inpatient High-Utilizer Patient

PDSA Cycle

Primary Care Provider

Primary Care Access

Quality Improvement