Targeting Superutilizers Does Not Impact Hospital Readmissions

Just five percent of the population accounts for about one-half of annual healthcare spending, but interventions that target these super-utilizers do little to impact hospital readmissions, according to a new study from MIT.

The study published last week in the New England Journal of Medicine found that superutilizers in a “hotspotting” program – a model that gives high-cost patients greater access to providers and social service resources in order to prevent rehospitalizations and other expensive forms of care – showed up at the hospital after an initial discharge almost the same number of times as super-utilizers not targeted by the program.

“Our results suggest that there are challenges for superutilizer programs aimed at medically and socially complex populations,” wrote the researchers from MIT. “It is possible that approaches to care management that are designed to connect patients with existing resources are insufficient for these complex cases.”

The study specifically examined a hotspotting program run by New Jersey-based Camden Coalition of Healthcare Partners (Coalition), a multi-disciplinary non-profit that works to advance complex care through person-centered programs that address chronic conditions and social barriers to well-being.

The Coalition’s hotspotting program uses real-time data on hospital admissions to identify superutilizers with chronic conditions and complex needs. The organization then helps superutilizers to navigate the healthcare system through an “intensive, face-to-face care model.” The program aims to improve patient outcomes while reducing unnecessary healthcare costs and utilization.

To study the impact the hotspotting program had on hospital readmission rates, MIT researchers evaluated 800 patients enrolled in the program from 2014 to 2017 who had been hospitalized at least once in the six months prior to an admission and had at least two chronic conditions, among other healthcare issues. Half of the study’s patients received the program’s services, while the rest were in a control group that did not partake.

Patients in the hotspotting program reported high engagement, with 95 percent of patients had at least three encounters with program staff, as well as intensive intervention (average of 7.6 home visits).

However, the 180-day readmission rate was 62.3 percent in the treatment group and 61.7 percent in the control group.

Additionally, two program goals related to the timing of services – a home visit within five days after hospital discharge and a visit to a provider’s office within seven days after discharge – were achieved less than 30 percent of the time.

The findings indicate challenges with reaching hotspotting goals, researchers stated.

“[M]any patients whose medical costs are high today will not be as high in the future — and this trend becomes even more pronounced as one goes higher in the cost distribution,” they wrote in the study. “Moreover, for patients with medical costs that are persistently high, few of those costs may be related to potentially preventable hospitalizations.”

The study also suggests challenges in reaching certain goals, such as timing of services, researchers added. The challenges include lack of stable housing or a telephone and behavioral health complexities, as well as few available appointments among providers.

“The difficulties that this pioneering, data-driven organization had in achieving rapid assistance for patients may portend difficulties in achieving it at scale,” researchers stated.

The study is shaking providers who have invested heavily in implementing interventions that target similar populations. But these providers should not abandon their hotspotting programs just yet, industry experts are saying.

“Although this new research requires us to recalibrate our industry's ultimate goals, it doesn't mean we need to slash and burn our current strategy,” said the Advisory Board’s Solomon Banjo, senior consultant at the Workforce Best Practice Collaborative, and Darby Sullivan, senior analyst and population health advisor. “For one, as well-known as the Camden model is, it is by no means the only evidence that supports high-risk care management or care transition support.”

Banjo and Sullivan elaborated that these highly complex patients require more than three months to stabilize and change their behavioral patterns.

“Newer programs increasingly prioritize community-based staffing; cultural competency and humility; and preventive outreach prior to admission,” they wrote. “The most promising interventions are those that measure success based on patient-centered measures like increased trust and activation levels.”

The Coalition is taking these findings and refining their programs to better influence patient outcomes.

“This study confirms what our care teams see every day—care management that focuses solely on healthcare is insufficient,” Kathleen Noonan, CEO of the Coalition, stated in a press release. “People with lifetimes of trauma and complexity are best supported by high-quality resources in the community and a healthcare environment designed to meet their needs.”

The Coalition will examine the impact of its hotspotting program on additional outcome measures and sub-populations, Noonan added. Meanwhile, the organization will continue to form partnerships to reduce barriers to care and unnecessary hospital utilization among the most medically complex patients.