Multi-Visit Patient Initiative Supports High-Risk Patients

By Amanda Jepson | Categories: | Comments Off on Multi-Visit Patient Initiative Supports High-Risk Patients

In 2019, boarding and left-without-being-seen rates at Harris Health’s Ben Taub Hospital were above goal, and executive leaders grew concerned about quality of care, patient safety, and staff burnout. Data analysis showed that Multi-Visit Patients (MVPs)—defined as patients with 10 or more emergency department (ED) visits in the past 365 days—accounted for 0.7 percent of all ED patients and 8 percent of all ED visits. High utilizers of the emergency department often visit hospitals because of multiple behavioral, social, and medical conditions. To decrease avoidable utilization, improve throughput and safety, and help an under-resourced population obtain care, Harris Health in 2020 leveraged the Multi-Visit Patient Method. 

Harris Health trained ED physicians, along with nursing, psychiatry, and care management staff, to become program champions. The program employs community health workers (CHWs) in the ED to communicate with MVPs, identify their root cause of frequent visits, and link them to necessary care and community resources. The team tracks key process measures on a weekly and monthly basis: percent of MVP ED visits with a face-to-face assessment, percent of MVP ED visits with a linkage to resources, and percent of unique MVPs with an MVP note in the electronic health record.  

Partnering with more than 11 community organizations, including the Houston Recovery Center and Coalition for the Homeless of Houston/Harris County, the MVP team has successfully built pathways to support MVPs with substance use disorder, end-stage renal disease (ESRD), behavioral health, and housing insecurity. Recognizing that a simple referral is not enough for MVPs, the team developed closed-loop communication procedures, including dedicated staff contacts, phone numbers, and MVP-specific operating hours and transportation services. 

The MVP team has reunited at least 10 MVPs with their families, obtained routine dialysis treatment for 26 MVPs with ESRD, connected 15 MVPs with substance use disorder to rehabilitation services, and helped 22 MVPs receive housing. In three years, the annual MVP visit count decreased by 23.2 percent (more than 1,500 annual visits), and total length of stay hours decreased by 36 percent (16,000 annual hours). MVPs who were engaged by CHWs on at least three-fourths of their visits showed a 57 percent decrease in ED visits during a 12-month follow-up.