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First Author: Rita K. Kuwahara, MIH, UNC Chapel Hill School of
Medicine, Class of 2016
Introduction: According to the Agency for Healthcare Research
and Quality, the top 1% of patients with multiple
rehospitalizations-the "super-utilizers" of the healthcare
system-account for 20% of the total $2.9 trillion spent annually on
U.S. healthcare costs. These medically/socially complex individuals
often have needs that substantially exceed the care available in
clinical practice. To better understand factors contributing to
these patients' use of healthcare, the objective of this study was
to use the Association of American Medical Colleges (AAMC) method
of "hotspotting" to collect the stories of "super-utilizer"
patients in central North Carolina to develop individualized care
plans that reduce rehospitalizations and improve health
Methods: In this qualitative study, an interprofessional team of
medical, social work, pharmacy, public policy, business, and
divinity students at UNC-Chapel Hill and Duke University identified
five "super-utilizer" patients with complex medical/social
histories and recurrent hospitalizations to enroll and follow for
3-4 months. Team members collected patient narratives to examine
underlying factors contributing to patients' health status/use of
healthcare, conducted home visits, accompanied patients to clinic
appointments, assisted patients with navigating the healthcare
system, interviewed patients' providers, and reviewed the medical
record. Enrolled patients had >3 hospitalizations in the past 12
months at UNC or Duke and >3 comorbidities. Patients under 18
years were excluded. Our project was funded through a hotspotting
minigrant from the AAMC, Camden Coalition of Healthcare Providers,
and Primary Care Progress, and was IRB exempt, as it was classified
as quality improvement.
Results: All enrolled patients had multiple unmet social needs
and >6 comorbidities, most commonly diabetes, heart failure,
chronic pain, dental problems, and depression. Of the five
patients, only two were retained throughout the study. Of the two
patients, one had 10 hospitalizations in the past year with 34
inpatient days, and the other had 7 hospitalizations with 124
inpatient days. Both patients had stable housing, and one patient
had strong social support. Both patients cited multiple
system-level failures contributing to their hospitalizations, but
neither was rehospitalized for the duration of the study, and
information obtained from interviews was used to enable better
navigation of the healthcare system, avoid previously encountered
system-level failures, and improve care. The three patients lost to
follow-up had less stable housing, a higher incidence of substance
abuse, and were less likely to have a primary care physician.
Conclusion: Our findings highlight the importance of
understanding patient narratives to develop interprofessional
interventions that comprehensively manage clinical/social needs,
reduce costs, and improve health outcomes. However, patients with
significant social barriers in greatest need of narrative-informed
care may be the most difficult to retain in interventions, and
require novel approaches to achieve optimal health.
January 2016 Issue of IMpact