Implementing new care strategies can cut health care usage among system's biggest users

Co-ordinating patient care better can reduce use of the health care system by its most frequently seen patients, according to new research published in the Canadian Medical Association Journal.

A small group of people are often admitted into hospital or frequently visit hospital emergency departments and clinics. These individuals are often seniors and people with chronic conditions—including mental health disorders—and they use a disproportionate amount of health care resources, despite their relatively small numbers.

"We looked at strategies to improve quality of care for frequent users and reduce their use of health care services," said Dr. Andrea Tricco, the lead author of the study and a scientist in the Li Ka Shing Knowledge Institute of St. Michael's Hospital. "We showed that patients who had better co-ordinated care were 20 per cent less likely to be admitted into hospital. Among the elderly, such strategies also decreased emergency department use by 31 per cent."

Researchers looked at several strategies for improving quality of care for frequent users. These included changing the way physicians deliver care and empowering patients in their own care. One common strategy was moving from practices where physicians were the sole care provider toward multidisciplinary teams that might include social workers, nurses and occupational therapists.

"Multidisciplinary teams often go hand in hand with case management – where someone other than the primary care physician co-ordinates the patient's care plan," said Dr. Tricco, who has a PhD in population health. "When case management is handled by a non-physician, such as a nurse or social worker, it is shown to improve outcomes for frequent users."

Quality improvement strategies aren't limited to changes in the way doctors care for their patients, however. Increasing opportunities for patients to manage their own care has been shown to effectively improve care for frequent users and reduce the burden on hospital admissions.

"Working with patients to establish joint goals and providing them with education and tools patients need, health care providers can empower patients to manage their disease on their own," said Dr. Tricco. "Examples are providing home glucometers for patients with diabetes who are on insulin or working with patients to come up with an action plan for discharge from the hospital. By giving these patients the tools and training – whether physical or emotional – to realize these goals, clinicians can help patients triage and better manage their disease day to day."

Using findings from 36 randomized controlled trials and 14 companion reports, St. Michael's researchers had data on how nearly 7,500 patients used the health care system. Many previous studies have looked at frequent users of emergency departments but there has been less research focused on users of the general health care system.

The study showed that strategies such as patient empowerment, changing case management and the move to multidisciplinary teams effectively reduced hospital admissions for all frequent users with physical ailments.

While effective for preventing frequent hospital admissions among those with chronic physical ailments, quality improvement strategies did not lessen usage of the health care system by people with mental health illness.

Dr. Tricco said that more research needs to be done to further improve the quality of care for frequent users and new strategies should be developed to make care better for frequent health care system users with mental illnesses.