Introduction: High-need, high-cost patients can over-utilize acute care services, a pattern of behavior associated with many poor outcomes that disproportionately contributes to increased US healthcare cost. Our objective was to reduce healthcare cost and improve outcomes by optimizing the system of care.  We targeted HNHC patients and identified root causes of frequent healthcare utilization.  We developed a cross-continuum intervention process and a succinct tool called a Complex Care Map (CCM)© that addresses fragmentation in the system and links providers to a comprehensive individualized analysis of the patient story and causes for frequent access to health services.

Methods: Using a pre/post test design, this quality improvement project focused on determining if the interdisciplinary intervention called CCM© had an impact on healthcare utilization and costs for HNHC patients.  Analysis was conducted between November 2012 and December 2015 at Mercy Health Saint Mary’s, a Midwestern urban hospital with greater than 80,000 annual emergency department visits.  Included patients had three or more hospital visits (ED or IP) in the 12 months prior to initiation of a CCM© (n=339).  Individualized CCMs© were created and made available in the Electronic Medical Record (EMR) to all healthcare providers. We compared utilization, cost, social, and healthcare access variables from the EMR and cost accounting system for 12 months before and after CCMs© implementation.  Both descriptive and limited inferential statistics were utilized.

Results: ED mean visits decreased 43% (p<0.001), inpatient mean admissions decreased 44% (p<0.001), outpatient mean visits decreased 17% (p<0.001), CT mean scans decreased 62% (p<0.001), and OBS/IP LOS mean days decreased 41% (p<0.001).  Gross charges decreased 45 % (p<0.001), direct expenses decreased 47% (p<0.001), contribution margin improved by 11% (p=0.002), and operating margin improved by 73% (p<0.001).  Patients with housing increased 14% (p<0.001), those with primary care increased 15% (p<0.001), and those with insurance increased 16% (p<0.001).

Introduction: Emergency physician (EP) turnover is a significant issue that can have strong economic impact on hospital systems, as well as implications on research efforts to test and improve clinical practice. This work is particularly important to researchers planning randomized trials directed toward EPs because a large degree of turnover within a physician group would attenuate the effectiveness of the desired intervention. We sought to determine the incidence and factors associated with EP workforce changes.

Methods: In an attempt to determine EP turnover and workforce change, data from the INSTINCT (INcreasing Stroke Treatment through INterventional behavior Change Tactics) trial were used. The INSTINCT trial is a prospective, cluster-randomized, controlled trial evaluating a targeted behavioral intervention to increase appropriate use of tissue plasminogen activator in acute ischemic stroke. Individual EPs staffing each of the study hospitals were identified at baseline and 18 months. Surveys were sent to EPs at both intervals. Models were constructed to investigate relationships between physician/hospital characteristics and workforce change.

Results: A total of 278 EPs were identified at baseline. Surveys were sent to all EPs at baseline and 18 months with a response rate of 72% and 74%, respectively. At 18 months, 37 (15.8%) had left their baseline hospital and 66 (26.3%) new EPs were working. Seven EPs switched hospitals within the sample. The total number of EPs at 18 months was 307, a 10.8% overall increase. Among the 24 hospitals, 6 had no EP departures and 5 had no new arrivals. The median proportion of EP workforce departing by hospital was 16% (interquartile range [IQR] ¼ 4%–25%; range ¼ 0%–73%), and the median proportion added was 21% (IQR ¼ 7%–41%; range ¼ 0%–120%). None of the evaluatedcovariates investigating relationships between physician/hospital characteristics and workforce change were significant.

Conclusion: EP workforce changes over an 18-month period were common. This has implications for emergency department directors, researchers, and individual EPs. Those planning research involvinginterventions upon EPs should account for turnover as it may have an impact when designing clinical trials to improve performance on healthcare delivery metrics for time-sensitive medical conditions suchas stroke, acute myocardial infarction, or trauma. [West J Emerg Med. 2013;14(1):16–22.]