Hospital Medicine Clinical Update – November 2019


Nationally, an extremely small number of patients (1%) account for a disproportionate burden of healthcare costs (22%). These patients are what are referred to as high utilizers and, not surprisingly, are more likely to have mental health or substance use disorders in addition to complex chronic medical illnesses. In early 2017, a dedicated group of multidisciplinary providers on 3West sought to better understand our local problem of 30-day readmissions and discovered that a small cohort of adult patients (n=10) with sickle cell disease (SCD) accounted for 7% of all readmissions to the General Medicine (GM) service and nearly $1million in annual costs. After conducting patient interviews to understand these patients’ experiences in care and exploring best practices for patients with SCD and high utilization, the use of longitudinal, multidisciplinary, individualized care plans (ICP) was identified as a promising approach. ICPs were subsequently developed through a care planning meeting with each patient/family and representation from all relevant disciplines, including nursing, social work, pharmacy, and various physician specialties. The plans provide a concise summary of each patient’s medical history and prior utilization and outline detailed strategies for optimal care across the inpatient-outpatient continuum; in essence, a roadmap to care for a “common presentation” of the patient’s chronic illness, with focus on complex pain and behavioral management. Once developed, these plans are published in EPIC for frontline providers to access from any point of care.

Impact analysis of the program 12 months post-intervention demonstrated meaningful reductions in 30-day readmissions, admissions, hospital bed days, and total costs in the pilot cohort. Anecdotally, patients praised the improved consistency in their care, and providers expressed appreciation for the effectiveness of ICPs in facilitating the care of complex patients. In 2018, based on the success of the pilot program, the program received central funding to expand to other patients with extremely high inpatient utilization (>four 30-day readmissions/year) with dedicated physician and nursing resources to further the program’s reach.

Beginning November 2018, program director Dr Inofuentes was joined by Teresa Radford as a Nurse Navigator to provide intensive care coordination for enrolled patients in the rebranded MSSL HOME team program.

Since the expansion, the HOME team has enrolled 13 additional patients with primary diagnoses ranging from Alcohol Use Disorder to Type 1 Diabetes to complications of quadriplegia. Additionally, the program has sought novel ways to approach and slow the cycle of high hospital utilization for patients with end-stage illnesses by enrolling select patients for advanced care planning. In an early analysis of program expansion for the first 5 enrolled patients, average monthly admissions and 30-day readmissions decreased modestly, and hospital bed days of care decreased by nearly 40%. Notable successes of the program include partnering with health system and community mental health resources to assist the service line’s most frequently admitted patient in completing an inpatient alcohol rehab program and securing Medicaid and permanent supportive housing and assisting another patient with alcoholism, COPD and significant cognitive decline in a transition to hospice provided in a skilled nursing environment.

In June, the HOME team program was recognized by the health system for excellence in patient care quality with the Charles L. Brown Award. This past summer, the HOME team began qualitative research of enrolled patients through structured interviews to better understand the impact of the program and ongoing barriers to better health from the patient’s perspective.This November, Dr Inofuentes will co-lead a workshop at the national meeting for the Center for Complex Health and Social Needs (Camden Coalition) on the importance of cross-sector teams in reducing utilization among patients with substance use and mental health disorders.


The hospitalist group has recently developed a relatively new avenue of service in the form of a hematology-oncology hospitalist service. This group evolved out of a growing need in the hematology and oncology service line for more providers to support its increasing patient needs, the rapidly expanding stem cell transplant program, and its rising number of clinical trials.

The hematology-oncology hospitalist primarily serves in three different domains: supervision of chemotherapy administration, management of medical problems associated with malignancies and their associated therapies, and assistance in caring for patients receiving autologous stem cell transplants. For patients receiving regularly scheduled chemotherapy, they are often admitted by an outpatient hematologist or oncologist to the service where they can be observed for toxicities associated with chemotherapy administration. The partnership with the hospitalists can help us aid in providing more access to care for patients with advanced hematologic and oncologic needs. UVA hematology and oncology patients who present to the hospital with medical problems manifesting as a result of their diseases or therapies often require inpatient care. In the past, this has largely been managed by the hematology/oncology attendings along with resident teams. zzUVA’s expertise has been increasingly recognized on a national scale, so have the needs to accommodate growing numbers of patients. The hematology-oncology hospitalist will aid in offloading that group so that we can allow for more patients to receive the excellent standard of care that UVA is accustomed to providing. Finally, the stem cell transplant program has been an area of surging growth. The program completed its milestone 500th transplant just this year. Given the medical complexity of some of these patients and associated treatments, the hospitalists have formed a partnership in which we can co-manage a patient’s complex medical problems and complications of transplants along with the hematology team to effectively extend the reach of care we can provide.

This has been a wonderful collaborative effort between Hematology/Oncology and the hospitalists, and we look forward to seeing how it will further grow and develop.

Filed Under: Clinical Research, News and Notes, Top News

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