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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