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Copyright (c) 2024 Afnan Abdullah Alrashidi, Hanan Abdullah Alrashidi, Gamyalh Saad Alrasheede, Saleh Binya Alanazi, Saud Mokhlif Alanze, Badar Kalifah Alharbi, Mohsen Dakhil Qablan Aldajaani, Mohsen Dukhail Alotaibi, Hamza Eissa Abdullah Basher, Mohammad Saeed Mordi Al Dawseri, Ali Mordi Fahad Aldosari, Moubark Obaid Saad Aldawsari, Reem Matook AL Saadi
This work is licensed under a Creative Commons Attribution 4.0 International License.
The "Super-Utilizer" Inpatient: A Team-Based Care Plan for Frequent Admitters
Corresponding Author(s) : Afnan Abdullah Alrashidi
Saudi Journal of Medicine and Public Health,
Vol. 1 No. 2 (2024)
Abstract
Background: A small subset of patients with complex medical, behavioral, and social needs—often termed "super-utilizers"—account for a disproportionately high volume of hospital admissions, readmissions, and healthcare expenditures. These individuals frequently cycle through acute care systems due to fragmented management of multimorbidity, polypharmacy, substance use, mental illness, and profound social determinants of health. Traditional, episodic hospital care fails to address the root causes of its utilization, leading to high costs, poor outcomes, and staff frustration. Aim: This narrative review synthesizes evidence from 2010-2024 on interdisciplinary, team-based inpatient care models specifically designed for super-utilizer patients. Methods: A comprehensive search of PubMed, CINAHL, Scopus, and health services research databases was conducted. Results: Evidence indicates that successful models hinge on early identification via health informatics flags, the co-creation of a unified care plan by residents and nurses, consistent relational care from health assistant nurses, and early physical therapy to combat deconditioning. These interventions, when bundled, demonstrate consistent reductions in 30-day readmission rates (15-40%) and length of stay for the target population by addressing clinical and psychosocial needs simultaneously. Conclusion: Managing super-utilizer inpatients requires a paradigm shift from reactive, disease-focused care to proactive, team-based stewardship of the whole patient. Investment in structured interdisciplinary protocols, supported by informatics and dedicated support roles, is essential to break the cycle of recurrent hospitalization and improve outcomes for this vulnerable population.
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- 1. Bailey, J. E., Surbhi, S., Wan, J. Y., Munshi, K. D., Waters, T. M., Binkley, B. L., ... & Graetz, I. (2019). Effect of intensive interdisciplinary transitional care for high-need, high-cost patients on quality, outcomes, and costs: a quasi-experimental study. Journal of General Internal Medicine, 34(9), 1815-1824. https://doi.org/10.1007/s11606-019-05082-8
- 2. Baldwin, S. M., Zook, S., & Sanford, J. (2018). Implementing posthospital interprofessional care team visits to improve care transitions and decrease hospital readmission rates. Professional Case Management, 23(5), 264-271. DOI: 10.1097/NCM.0000000000000284
- 3. Bellon, J. E., Bilderback, A., Ahuja‐Yende, N. S., Wilson, C., Altieri Dunn, S. C., Brodine, D., & Boninger, M. L. (2019). University of Pittsburgh Medical Center home transitions multidisciplinary care coordination reduces readmissions for older adults. Journal of the American Geriatrics Society, 67(1), 156-163. https://doi.org/10.1111/jgs.15643
- 4. Berkowitz, S. A., Hulberg, A. C., Hong, C., Stowell, B. J., Tirozzi, K. J., Traore, C. Y., & Atlas, S. J. (2016). Addressing basic resource needs to improve primary care quality: a community collaboration programme. BMJ quality & safety, 25(3), 164-172. https://doi.org/10.1136/bmjqs-2015-004521
- 5. Berkowitz, S. A., Parashuram, S., Rowan, K., Andon, L., Bass, E. B., Bellantoni, M., ... & Brown, P. M. (2018). Association of a care coordination model with health care costs and utilization: the Johns Hopkins Community Health Partnership (J-CHiP). JAMA network open, 1(7), e184273-e184273. doi:10.1001/jamanetworkopen.2018.4273
- 6. Carter, J. A., Carr, L. S., Collins, J., Petrongolo, J. D., Hall, K., Murray, J., ... & Tata, L. A. (2015). STAAR: improving the reliability of care coordination and reducing hospital readmissions in an academic medical centre. BMJ innovations, 1(3). https://doi.org/10.1136/bmjinnov-2015-000048
- 7. Chakurian, D., & Popejoy, L. (2021). Utilizing the care coordination Atlas as a framework: an integrative review of transitional care models. International Journal of Care Coordination, 24(2), 57-71. https://doi.org/10.1177/20534345211001615
- 8. Chang, E., Ali, R., Seibert, J., & Berkman, N. D. (2023). Interventions to improve outcomes for high-need, high-cost patients: a systematic review and meta-analysis. Journal of general internal medicine, 38(1), 185-194. https://doi.org/10.1007/s11606-022-07809-6
- 9. Figueroa, J. F., & Jha, A. K. (2018). Approach for achieving effective care for high-need patients. JAMA Internal Medicine, 178(6), 845-846. doi:10.1001/jamainternmed.2018.0823
- 10. Finkelstein, A., Zhou, A., Taubman, S., & Doyle, J. (2020). Health care hotspotting—a randomized, controlled trial. New England Journal of Medicine, 382(2), 152-162. DOI: 10.1056/NEJMsa1906848
- 11. Gentene, A. J., Guido, M. R., Woolf, B., Dalhover, A., Boesken, T. A., Mueller, E. W., & Zafar, M. A. (2021). Multidisciplinary team utilizing pharmacists in multimodal, bundled care reduce chronic obstructive pulmonary disease hospital readmission rates. Journal of Pharmacy Practice, 34(1), 110-116. https://doi.org/10.1177/0897190019889440
- 12. Greenwood-Lee, J., Jewett, L., Woodhouse, L., & Marshall, D. A. (2018). A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC health services research, 18(1), 986. https://doi.org/10.1186/s12913-018-3745-y
- 13. Hong, C. S., Siegel, A. L., & Ferris, T. G. (2014). Caring for high-need, high-cost patients: what makes for a successful care management program?.
- 14. Hoyer, E. H., Brotman, D. J., Apfel, A., Leung, C., Boonyasai, R. T., Richardson, M., ... & Deutschendorf, A. (2018). Improving outcomes after hospitalization: a prospective observational multicenter evaluation of care coordination strategies for reducing 30-day readmissions to Maryland hospitals. Journal of general internal medicine, 33(5), 621-627. https://doi.org/10.1007/s11606-017-4218-4
- 15. Hoyer, E. H., Friedman, M., Lavezza, A., Wagner‐Kosmakos, K., Lewis‐Cherry, R., Skolnik, J. L., ... & Needham, D. M. (2016). Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality‐improvement project. Journal of hospital medicine, 11(5), 341-347. https://doi.org/10.1002/jhm.2546
- 16. Jackevicius, C. A., de Leon, N. K., Lu, L., Chang, D. S., Warner, A. L., & Mody, F. V. (2015). Impact of a multidisciplinary heart failure post-hospitalization program on heart failure readmission rates. Annals of Pharmacotherapy, 49(11), 1189-1196. https://doi.org/10.1177/1060028015599637
- 17. Kalisch, B. J., Xie, B., & Dabney, B. W. (2014). Patient-reported missed nursing care correlated with adverse events. American Journal of Medical Quality, 29(5), 415-422. https://doi.org/10.1177/1062860613501715
- 18. Kapoor, R., Avendaño, L., Sandoval, M. A., Cruz, A. T., Sampayo, E. M., Soto, M. A., ... & Crouse, H. L. (2017). Initiating a standardized regional referral and counter-referral system in Guatemala: a mixed-methods study. Global pediatric health, 4, 2333794X17719205. https://doi.org/10.1177/2333794X17719205
- 19. Kitzman, D. W., Whellan, D. J., Duncan, P., Pastva, A. M., Mentz, R. J., Reeves, G. R., ... & O’Connor, C. M. (2021). Physical rehabilitation for older patients hospitalized for heart failure. New England Journal of Medicine, 385(3), 203-216. DOI: 10.1056/NEJMoa2026141
- 20. Maghsoud-Lou, E., Christie, S., Abidi, S. R., & Abidi, S. S. R. (2017). Protocol-driven decision support within e-Referral systems to streamline patient consultation, triaging and referrals from primary care to specialist clinics. Journal of Medical Systems, 41(9), 139. https://doi.org/10.1007/s10916-017-0791-7
- 21. McLaughlin, F., Henn, J., & Candelario, D. (2017). Reduce readmissions and improve transitional care services: An interdisciplinary team provides effective, high-quality discharge care. American Nurse Today, 12(12), 44-47. https://link.gale.com/apps/doc/A523795449/HRCA?u=anon~425c7420&sid=googleScholar&xid=e0b8c2e4
- 22. Moe, J., Kirkland, S. W., Rawe, E., Ospina, M. B., Vandermeer, B., Campbell, S., & Rowe, B. H. (2017). Effectiveness of interventions to decrease emergency department visits by adult frequent users: a systematic review. Academic Emergency Medicine, 24(1), 40-52. https://doi.org/10.1111/acem.13060
- 23. Naylor, M. D., Hirschman, K. B., McCauley, K., Shaid, E. C., Hanlon, A. L., Whitehouse, C. R., ... & Pauly, M. V. (2022). MIRROR-TCM: multisite replication of a randomized controlled trial-Transitional care model. Contemporary clinical trials, 112, 106620. https://doi.org/10.1016/j.cct.2021.106620
- 24. O'leary, K. J., Sehgal, N. L., Terrell, G., Williams, M. V., & High Performance Teams and the Hospital of the Future Project Team. (2012). Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement. Journal of hospital medicine, 7(1), 48-54. https://doi.org/10.1002/jhm.970
- 25. Palimbo, A., Salmah, A. U., Amiruddin, R., & Syam, A. (2021). An overview of the implementation of the continuity of care model in maternal health services: A literature review. Gaceta sanitaria, 35, S388-S392. https://doi.org/10.1016/j.gaceta.2021.10.058
- 26. Rostagno, C., Buzzi, R., Campanacci, D., Boccacini, A., Cartei, A., Virgili, G., ... & Marchionni, N. (2016). In hospital and 3-month mortality and functional recovery rate in patients treated for hip fracture by a multidisciplinary team. PloS one, 11(7), e0158607. https://doi.org/10.1371/journal.pone.0158607
- 27. Shams, I., Ajorlou, S., & Yang, K. (2015). A predictive analytics approach to reducing 30-day avoidable readmissions among patients with heart failure, acute myocardial infarction, pneumonia, or COPD. Health care management science, 18(1), 19-34. https://doi.org/10.1007/s10729-014-9278-y
- 28. Spagnolo, J., Breton, M., Sasseville, M., Sauvé, C., Clément, J. F., Fleet, R., ... & Beauséjour, M. (2021). Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec. BMC health services research, 21(1), 1345. https://doi.org/10.1186/s12913-021-07286-3
- 29. Snyder, M. E., Krekeler, C. E., Jaynes, H. A., Davis, H. B., Lantaff, W. M., Shan, M., ... & Zillich, A. J. (2020). Evaluating the effects of a multidisciplinary transition care management program on hospital readmissions. American Journal of Health-System Pharmacy, 77(12), 931-937. https://doi.org/10.1093/ajhp/zxaa091
- 30. Van Walraven, C., Dhalla, I. A., Bell, C., Etchells, E., Stiell, I. G., Zarnke, K., ... & Forster, A. J. (2010). Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. Cmaj, 182(6), 551-557. https://doi.org/10.1503/cmaj.091117
- 31. Wåhlberg, H., Valle, P. C., Malm, S., Hovde, Ø., & Broderstad, A. R. (2017). The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial. BMC Health Services Research, 17(1), 177. https://doi.org/10.1186/s12913-017-2127-1
- 32. Weaver, N., Coffey, M., & Hewitt, J. (2017). Concepts, models and measurement of continuity of care in mental health services: a systematic appraisal of the literature. Journal of Psychiatric and Mental Health Nursing, 24(6), 431-450. https://doi.org/10.1111/jpm.12387
- 33. Zador, Z., Landry, A., Cusimano, M. D., & Geifman, N. (2019). Multimorbidity states associated with higher mortality rates in organ dysfunction and sepsis: a data-driven analysis in critical care. Critical Care, 23(1), 247. https://doi.org/10.1186/s13054-019-2486-6
References
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2. Baldwin, S. M., Zook, S., & Sanford, J. (2018). Implementing posthospital interprofessional care team visits to improve care transitions and decrease hospital readmission rates. Professional Case Management, 23(5), 264-271. DOI: 10.1097/NCM.0000000000000284
3. Bellon, J. E., Bilderback, A., Ahuja‐Yende, N. S., Wilson, C., Altieri Dunn, S. C., Brodine, D., & Boninger, M. L. (2019). University of Pittsburgh Medical Center home transitions multidisciplinary care coordination reduces readmissions for older adults. Journal of the American Geriatrics Society, 67(1), 156-163. https://doi.org/10.1111/jgs.15643
4. Berkowitz, S. A., Hulberg, A. C., Hong, C., Stowell, B. J., Tirozzi, K. J., Traore, C. Y., & Atlas, S. J. (2016). Addressing basic resource needs to improve primary care quality: a community collaboration programme. BMJ quality & safety, 25(3), 164-172. https://doi.org/10.1136/bmjqs-2015-004521
5. Berkowitz, S. A., Parashuram, S., Rowan, K., Andon, L., Bass, E. B., Bellantoni, M., ... & Brown, P. M. (2018). Association of a care coordination model with health care costs and utilization: the Johns Hopkins Community Health Partnership (J-CHiP). JAMA network open, 1(7), e184273-e184273. doi:10.1001/jamanetworkopen.2018.4273
6. Carter, J. A., Carr, L. S., Collins, J., Petrongolo, J. D., Hall, K., Murray, J., ... & Tata, L. A. (2015). STAAR: improving the reliability of care coordination and reducing hospital readmissions in an academic medical centre. BMJ innovations, 1(3). https://doi.org/10.1136/bmjinnov-2015-000048
7. Chakurian, D., & Popejoy, L. (2021). Utilizing the care coordination Atlas as a framework: an integrative review of transitional care models. International Journal of Care Coordination, 24(2), 57-71. https://doi.org/10.1177/20534345211001615
8. Chang, E., Ali, R., Seibert, J., & Berkman, N. D. (2023). Interventions to improve outcomes for high-need, high-cost patients: a systematic review and meta-analysis. Journal of general internal medicine, 38(1), 185-194. https://doi.org/10.1007/s11606-022-07809-6
9. Figueroa, J. F., & Jha, A. K. (2018). Approach for achieving effective care for high-need patients. JAMA Internal Medicine, 178(6), 845-846. doi:10.1001/jamainternmed.2018.0823
10. Finkelstein, A., Zhou, A., Taubman, S., & Doyle, J. (2020). Health care hotspotting—a randomized, controlled trial. New England Journal of Medicine, 382(2), 152-162. DOI: 10.1056/NEJMsa1906848
11. Gentene, A. J., Guido, M. R., Woolf, B., Dalhover, A., Boesken, T. A., Mueller, E. W., & Zafar, M. A. (2021). Multidisciplinary team utilizing pharmacists in multimodal, bundled care reduce chronic obstructive pulmonary disease hospital readmission rates. Journal of Pharmacy Practice, 34(1), 110-116. https://doi.org/10.1177/0897190019889440
12. Greenwood-Lee, J., Jewett, L., Woodhouse, L., & Marshall, D. A. (2018). A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC health services research, 18(1), 986. https://doi.org/10.1186/s12913-018-3745-y
13. Hong, C. S., Siegel, A. L., & Ferris, T. G. (2014). Caring for high-need, high-cost patients: what makes for a successful care management program?.
14. Hoyer, E. H., Brotman, D. J., Apfel, A., Leung, C., Boonyasai, R. T., Richardson, M., ... & Deutschendorf, A. (2018). Improving outcomes after hospitalization: a prospective observational multicenter evaluation of care coordination strategies for reducing 30-day readmissions to Maryland hospitals. Journal of general internal medicine, 33(5), 621-627. https://doi.org/10.1007/s11606-017-4218-4
15. Hoyer, E. H., Friedman, M., Lavezza, A., Wagner‐Kosmakos, K., Lewis‐Cherry, R., Skolnik, J. L., ... & Needham, D. M. (2016). Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality‐improvement project. Journal of hospital medicine, 11(5), 341-347. https://doi.org/10.1002/jhm.2546
16. Jackevicius, C. A., de Leon, N. K., Lu, L., Chang, D. S., Warner, A. L., & Mody, F. V. (2015). Impact of a multidisciplinary heart failure post-hospitalization program on heart failure readmission rates. Annals of Pharmacotherapy, 49(11), 1189-1196. https://doi.org/10.1177/1060028015599637
17. Kalisch, B. J., Xie, B., & Dabney, B. W. (2014). Patient-reported missed nursing care correlated with adverse events. American Journal of Medical Quality, 29(5), 415-422. https://doi.org/10.1177/1062860613501715
18. Kapoor, R., Avendaño, L., Sandoval, M. A., Cruz, A. T., Sampayo, E. M., Soto, M. A., ... & Crouse, H. L. (2017). Initiating a standardized regional referral and counter-referral system in Guatemala: a mixed-methods study. Global pediatric health, 4, 2333794X17719205. https://doi.org/10.1177/2333794X17719205
19. Kitzman, D. W., Whellan, D. J., Duncan, P., Pastva, A. M., Mentz, R. J., Reeves, G. R., ... & O’Connor, C. M. (2021). Physical rehabilitation for older patients hospitalized for heart failure. New England Journal of Medicine, 385(3), 203-216. DOI: 10.1056/NEJMoa2026141
20. Maghsoud-Lou, E., Christie, S., Abidi, S. R., & Abidi, S. S. R. (2017). Protocol-driven decision support within e-Referral systems to streamline patient consultation, triaging and referrals from primary care to specialist clinics. Journal of Medical Systems, 41(9), 139. https://doi.org/10.1007/s10916-017-0791-7
21. McLaughlin, F., Henn, J., & Candelario, D. (2017). Reduce readmissions and improve transitional care services: An interdisciplinary team provides effective, high-quality discharge care. American Nurse Today, 12(12), 44-47. https://link.gale.com/apps/doc/A523795449/HRCA?u=anon~425c7420&sid=googleScholar&xid=e0b8c2e4
22. Moe, J., Kirkland, S. W., Rawe, E., Ospina, M. B., Vandermeer, B., Campbell, S., & Rowe, B. H. (2017). Effectiveness of interventions to decrease emergency department visits by adult frequent users: a systematic review. Academic Emergency Medicine, 24(1), 40-52. https://doi.org/10.1111/acem.13060
23. Naylor, M. D., Hirschman, K. B., McCauley, K., Shaid, E. C., Hanlon, A. L., Whitehouse, C. R., ... & Pauly, M. V. (2022). MIRROR-TCM: multisite replication of a randomized controlled trial-Transitional care model. Contemporary clinical trials, 112, 106620. https://doi.org/10.1016/j.cct.2021.106620
24. O'leary, K. J., Sehgal, N. L., Terrell, G., Williams, M. V., & High Performance Teams and the Hospital of the Future Project Team. (2012). Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement. Journal of hospital medicine, 7(1), 48-54. https://doi.org/10.1002/jhm.970
25. Palimbo, A., Salmah, A. U., Amiruddin, R., & Syam, A. (2021). An overview of the implementation of the continuity of care model in maternal health services: A literature review. Gaceta sanitaria, 35, S388-S392. https://doi.org/10.1016/j.gaceta.2021.10.058
26. Rostagno, C., Buzzi, R., Campanacci, D., Boccacini, A., Cartei, A., Virgili, G., ... & Marchionni, N. (2016). In hospital and 3-month mortality and functional recovery rate in patients treated for hip fracture by a multidisciplinary team. PloS one, 11(7), e0158607. https://doi.org/10.1371/journal.pone.0158607
27. Shams, I., Ajorlou, S., & Yang, K. (2015). A predictive analytics approach to reducing 30-day avoidable readmissions among patients with heart failure, acute myocardial infarction, pneumonia, or COPD. Health care management science, 18(1), 19-34. https://doi.org/10.1007/s10729-014-9278-y
28. Spagnolo, J., Breton, M., Sasseville, M., Sauvé, C., Clément, J. F., Fleet, R., ... & Beauséjour, M. (2021). Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec. BMC health services research, 21(1), 1345. https://doi.org/10.1186/s12913-021-07286-3
29. Snyder, M. E., Krekeler, C. E., Jaynes, H. A., Davis, H. B., Lantaff, W. M., Shan, M., ... & Zillich, A. J. (2020). Evaluating the effects of a multidisciplinary transition care management program on hospital readmissions. American Journal of Health-System Pharmacy, 77(12), 931-937. https://doi.org/10.1093/ajhp/zxaa091
30. Van Walraven, C., Dhalla, I. A., Bell, C., Etchells, E., Stiell, I. G., Zarnke, K., ... & Forster, A. J. (2010). Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. Cmaj, 182(6), 551-557. https://doi.org/10.1503/cmaj.091117
31. Wåhlberg, H., Valle, P. C., Malm, S., Hovde, Ø., & Broderstad, A. R. (2017). The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial. BMC Health Services Research, 17(1), 177. https://doi.org/10.1186/s12913-017-2127-1
32. Weaver, N., Coffey, M., & Hewitt, J. (2017). Concepts, models and measurement of continuity of care in mental health services: a systematic appraisal of the literature. Journal of Psychiatric and Mental Health Nursing, 24(6), 431-450. https://doi.org/10.1111/jpm.12387
33. Zador, Z., Landry, A., Cusimano, M. D., & Geifman, N. (2019). Multimorbidity states associated with higher mortality rates in organ dysfunction and sepsis: a data-driven analysis in critical care. Critical Care, 23(1), 247. https://doi.org/10.1186/s13054-019-2486-6