Health Care Hotspotting — A Randomized, Controlled Trial

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Abstract

There is widespread interest in programs aiming to reduce spending and improve quality among “super-utilizers,” patients with very high use of healthcare services. The Camden Coalition of Healthcare Providers’ (the Coalition) “Hotspotting” program has received national attention as a promising super-utilizer intervention and has been expanded to cities around the country. In the months following hospital discharge, a team of nurses, social workers and community health workers visit enrolled patients to coordinate outpatient care and to link them with social services. We randomized 800 medically and socially complex hospitalized patients, all with at least one additional hospitalization in the prior six months, to the Coalition’s care transition program or to usual care. The primary outcome was hospital readmission within 180 days post-discharge. The 180-day readmission rate was 61.7 percent in the control group and 62.3 percent in the intervention group. The adjusted difference between the groups was not significant (0.82 percentage points, 95% CI −5.97 to 7.61). By contrast, comparing the intervention-group admissions during the six months before and after enrollment misleadingly suggested a 38 percentage point decline in admissions from the intervention, because it did not account for the similar decline in the control group. In this randomized controlled study of patients with very high use of healthcare services, readmission rates were not lower for patients randomized to the Coalition’s program compared to usual care. (Funded by the National Institute on Aging, J-PAL North America, and MIT Sloan School of Management; ClinicalTrials.gov number, and the American Economic Association registry number, AEARCTR-0000329.)

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Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

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