Care coordination can decrease health-care use by frequent users

People who frequently visit emergency departments and clinics and are admitted to hospital use a disproportionate amount of health care resources despite their relatively small numbers. Many previous studies have looked at frequent users of emergency departments, but there has been less focus on users of the general health care system.

A team of Toronto-based researchers looked at what changes and quality improvements could be made to decrease health care usage -- care coordination strategies -- by frequent users. They analyzed 36 randomized controlled trials and 14 companion reports (total 7494 patients). For patients receiving a care coordination quality improvement strategy compared with usual care, they found a 20% decrease in hospital admissions and a 31% decrease in visits to the emergency department by older patients. However, the same approach did not lessen use of the health care system by people with mental illness.

"We found that quality improvement strategies focused on the coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients," writes Dr. Andrea Tricco, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, and the Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, with coauthors. "The strategies were not effective in reducing the use of health care services among patients with mental illness."

Case management (coordination of patients' care by someone other than a primary physician), empowering patients to manage their own health, making changes to the way the primary health care team functions and patient education significantly reduced hospital admissions.

"Patient education and promotion of self-management are likely less resource intensive than case management interventions are, which suggests that quality improvement strategies targeting patients (as opposed to clinicians) might be an efficient use of resources," write the authors.

They suggest that innovative strategies are needed to help reduce health care use by people with mental illness.

In a related commentary, Dr. Cara Tannenbaum, Université de Montréal, Montréal, Quebec, writes, "Individuals with mental illness may depend on hospital care for respite and safe supervision when acute episodes of psychosis or depression occur. Until our health care system offers an alternate point of access to these services, or adequately trains and supports caregivers to care for their loved ones at home during periods of illness exacerbation, the revolving door that allows entry into hospital will still continue to play an essential role in the care of patients with chronic conditions."