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Winning Abstracts from the 2015 Medical Student Abstract Competition: Understanding the Stories of "Super-Utilizer" Patients through Hotspotting on Tobacco Road: An Interprofessional Narrative-Based Approach to Reduce Rehospitalizations and Provide High
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 outcomes.
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.