Interventions for Frequently Hospitalized Patients and Their Effect on Outcomes: A Systematic Review

Alexandra Goodwin
Bruce L. Henschen
Linda C. O'Dwyer
Natasha Nichols
Kevin J. O'Leary
Peer-Reviewed Article
December 2018

This resource reviews interventions for frequently hospitalized patients and assesses the effectiveness of these interventions.

  • Health care organizations have begun to implement interventions that supplement or redesign care for frequently hospitalized patients.
  • In the nine studies selected, the majority of interventions added direct services or support – most commonly, a social worker – to standard care. Other common themes included caring for patients across settings and incorporating information technology into workflows.
  • Overall, studies reported mixed results. While low-quality studies found reductions in hospital use over time, higher quality studies found similar reductions in utilization between the intervention and control groups.
  • Care fragmentation probably plays an important role in the risk for readmissions in this population; interventions that address factors across the continuum of care may be more likely to succeed.
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