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Improving Care Transitions: Complex High-Utilizing Patient Experiences Guide Reform
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Improving Care Transitions: Complex High-Utilizing Patient Experiences Guide Reform

Nancy Ambrose Gallagher, PhD, APRN-BC; Donna Fox, RN; Carrie Dawson, MS, RN; and Brent C. Williams, MD, MPH
The authors audited a series of complex patients’ records longitudinally across their institution’s existing care management programs to improve the coordinated functioning of these programs.
In early 2015, monthly meetings between inpatient care managers and CCMP care managers grew to include primary care–based care managers. Through most of 2015, meetings focused on communication and documentation protocols to enhance the visibility of care planning notes among inpatient, CCMP, and outpatient care managers, for example, by creating a new, more recognizable label for EHR encounters (eg, “complex care management” rather than the more generic “telephone note”). Early recognition of CCMP patients by inpatient care managers was improved through use of a flagging system in the EHR that indicated the patient’s enrollment in the CCMP and contact information for the CCMP care manager, allowing them to be invited to inpatient care planning meetings. In 2016, outpatient social workers began to participate in these care planning meetings. Bolstered by relationships established at these meetings, joint assessment and care planning are now routine and referrals from inpatient care managers to those from the CCMP have increased. The value of the CCMP in behavioral management planning and bridging between inpatient settings and primary care also motivated increased communication between inpatient and ED care managers and CCMP; these groups now meet regularly for patient care planning and process improvement. Use of a consistent EHR across all levels of care in the health system has also improved communication. 

In addition to communication within the health system, communication is critical between the health system care management programs and community services providing patients with ongoing treatment or safer hospital transitions. Although incompatible EHRs remain, it was clear that case managers in both the health system and community worked to identify services relevant to patients’ physical and psychological conditions. In some cases, medications or treatments were obtained after substantial communication with insurance companies, specialty care providers, or pharmacies. In others, identifying relevant nonmedical community services improved patients’ self-management of their chronic conditions. For example, 2 patients improved after low-cost counseling was identified and provided for depression and anxiety, 2 after movement to group homes, and 1 after becoming sober. Regular meetings are also held among CCMP personnel and community agencies.

Improving care planning around behavioral conditions is recognized as a priority but has been more difficult to address. Barriers include the historical lack of involvement by Community Mental Health providers when patients undergo a medical admission, even when care of the medical condition is complicated by the patient’s psychological condition. A work group including University of Michigan Psychiatry, the CCMP, inpatient care management, and Community Mental Health is being convened to facilitate communication among these settings while patients are in the ED or inpatient services. 

Readmission Rates

Despite improvements in early recognition, patient-specific root-cause analysis, and coordinated care planning, 30-day hospital readmission rates for all hospitalizations among CCMP clients have been relatively stable over time (Figure). Patient-specific readmission rates showed similar results (not shown). 


We undertook a patient-centered approach to begin to develop process solutions to reduce readmissions and support patients as they transition from inpatient to community settings. We used a readily available resource, longitudinal patient records, to examine patient experiences across levels of care and community services. Coordination gaps identified were used to develop improved communication processes among the multiple settings providing services to this population. Other factors contributing to readmissions were varied and included the complexity and severity of medical conditions, psychological and socioeconomic conditions that complicated disease management and care access, and substance use. This is consistent with prior work finding that lack of social support or resources, a history of substance abuse and/or mental illness, and difficulty obtaining medication or transportation impacted posthospital transitions of adults,16 veterans,17 and homeless individuals.18  

Several factors may explain the lack of effect on hospital readmission rates among CCMP patients. Overall, the portion of preventable hospital costs among high-risk populations has been estimated at just 6%.19 In addition, studies demonstrating a relationship between effective discharge planning and decreased readmission rates have largely not been conducted in this population.20 Decreasing avoidable hospitalizations in this population will likely require larger system reforms that address psychosocial determinants of health, the supply of behavioral health providers, and improved coordination of social service organizations with primary care. 

Although the system modifications we have begun have not resulted in measurable reductions in readmission rates, important changes have occurred. By using a review of patient experiences as a starting point rather than administrative protocols, new and productive conversations across units occurred. Previously siloed care managers in inpatient and ED settings now meet regularly with outpatient care managers to coordinate care for individual patients. Care management documentation protocols have been shared and made more visible in the EHR across units. Perhaps most importantly, working relationships among staff and managers from different administrative units have developed, fostering interest in continuing to find new ways to promote patient-centered, rather than unit-centered, care management at all levels, including care managers, program management, and senior leadership.


Only qualitative analysis was conducted; future research should include quantitative analysis of other factors such as length of stay and cost. In addition, the sample size was small, limiting generalizability. Finally, only 3 quarters were examined. However, consistent themes emerged across patients, suggesting that relevant factors had been identified for this population.


Effective care management programs for populations with medical, psychological, and social issues require collaboration across levels and disciplines, particularly with mental health and substance use providers,3,14 identification of patients at high risk of readmission,21,22 involvement of interdisciplinary teams in ongoing patient care,23 and building of trusting relationships between patients and care providers.7 However, development of horizontal organizational reforms that require collaboration across administrative units can be challenging in organizations where these units have historically operated independently. Using actual patients’ longitudinal experiences across inpatient and outpatient settings can help break down barriers to collaboration and joint planning, and foster trust and cultural transformation to promote further reform.

Author Affiliations: University of Michigan (NG, CD, BCW), Ann Arbor, MI; Complex Care Management Program, University of Michigan (DF, BCW), Ann Arbor, MI.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (NG, CD, BCW); acquisition of data (NG, DF); analysis and interpretation of data (NG, DF, CD, BCW); drafting of the manuscript (NG, CD, BCW); critical revision of the manuscript for important intellectual content (NG, DF, CD, BCW); qualitative analysis (NG, BW); provision of patients or study materials (DF, BW); administrative, technical, or logistic support (DF, CD); and supervision (BCW).

Address Correspondence to: Nancy Ambrose Gallagher, PhD, APRN-BC, University of Michigan School of Nursing, 400 NIB, #2174, Ann Arbor, MI 48109. E-mail:

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