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Project: Management of High-Need, High-Cost Patients: A “Best Fit” Framework Synthesis, Realist Review, and Systematic Review

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Project Summary

Title and Description


Key Questions


Associated Extraction Forms

Title Created by Key Questions Addressed Form Notes
KQ 1 Qualitative Studies Extraction Form Rania Ali 1
KQ 3 Evidence Table Rania Ali 3


Associated Studies (each link opens a new tab)

Title Author Year
Persistent Super-Utilization of Acute Care Services Among Subgroups of Veterans Experiencing Homelessness. Szymkowiak D., Montgomery AE., Johnson EE., Manning T., O'Toole TP. 2017
Understanding Frequent Emergency Department Use Among Primary Care Patients. Hardy M., Cho A., Stavig A., Bratcher M., Dillard J., Greenblatt L., Schulman K. 2018
Factors associated with high-utilization in a safety net setting. Bell J., Turbow S., George M., Ali MK. 2017
Covariates of depression and high utilizers of healthcare: Impact on resource use and costs. Robinson RL., Grabner M., Palli SR., Faries D., Stephenson JJ. 2016
Illness severity and total visits in family medicine. Rohrer JE., Rasmussen N., Adamson SA. 2008
Association of behavioral health factors and social determinants of health with high and persistently high healthcare costs. Sterling S., Chi F., Weisner C., Grant R., Pruzansky A., Bui S., Madvig P., Pearl R. 2018
Identifying High Health Care Utilizers Using Post-Regression Residual Analysis of Health Expenditures from a State Medicaid Program. Yang C., Delcher C., Shenkman E., Ranka S. 2017
Diagnosis isn't enough: Understanding the connections between high health care utilization, chronic conditions and disabilities among U.S. working age adults. Reichard A., Gulley SP., Rasch EK., Chan L. 2015
Machine learning approaches for predicting high cost high need patient expenditures in health care. Yang C., Delcher C., Shenkman E., Ranka S. 2018
Using item response theory with health system data to identify latent groups of patients with multiple health conditions. Prenovost KM., Fihn SD., Maciejewski ML., Nelson K., Vijan S., Rosland AM. 2018
Emergency department use and barriers to wellness: a survey of emergency department frequent users. Birmingham LE., Cochran T., Frey JA., Stiffler KA., Wilber ST. 2017
Persistent Frequent Emergency Department Use: Core Group Exhibits Extreme Levels Of Use For More Than A Decade. Kanzaria HK., Niedzwiecki MJ., Montoy JC., Raven MC., Hsia RY. 2017
What can five high cost patients teach us about healthcare spending? Ganguli I., Thompson RW., Ferris TG. 2017
Emergency Department Frequent Utilization for Non-Emergent Presentments: Results from a Regional Urban Trauma Center Study. Behr JG., Diaz R. 2016
Risk Factors for Persistent Frequent Emergency Department Use in Medicare Beneficiaries. Colligan EM., Pines JM., Colantuoni E., Howell B., Wolff JL. 2016
Characteristics of Frequent Users of the Emergency Department with Psychiatric Conditions. Buhumaid R., Riley J., Sattarian M., Bregman B., Blanchard J. 2015
Predictors of Frequent Emergency Room Visits among a Homeless Population. Thakarar K., Morgan JR., Gaeta JM., Hohl C., Drainoni ML. 2015
Frequent users of US emergency departments: characteristics and opportunities for intervention. Vinton DT., Capp R., Rooks SP., Abbott JT., Ginde AA. 2014
Frequent utilization of the emergency department for acute heart failure syndrome: a population-based study. Hasegawa K., Tsugawa Y., Camargo CA., Brown DF. 2014
Frequent utilization of the emergency department for acute exacerbation of chronic obstructive pulmonary disease. Hasegawa K., Tsugawa Y., Tsai CL., Brown DF., Camargo CA. 2014
A multicenter observational study of US adults with acute asthma: who are the frequent users of the emergency department? Hasegawa K., Sullivan AF., Tovar Hirashima E., Gaeta TJ., Fee C., Turner SJ., Massaro S., Camargo CA. -- Not Found --
Reasons for emergency department use: do frequent users differ? Doran KM., Colucci AC., Wall SP., Williams ND., Hessler RA., Goldfrank LR., Raven MC. 2014
Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints? Liu SW., Nagurney JT., Chang Y., Parry BA., Smulowitz P., Atlas SJ. 2013
Predictors of frequent emergency department use among patients with psychiatric illness. Chang G., Weiss AP., Orav EJ., Rauch SL. -- Not Found --
Dispelling an urban legend: frequent emergency department users have substantial burden of disease. Billings J., Raven MC. 2013
Characteristics and predictors of frequent utilization of emergency services. Milbrett P., Halm M. 2009
Characteristics of frequent users of emergency departments. Hunt KA., Weber EJ., Showstack JA., Colby DC., Callaham ML. 2006
Use of the emergency department for severe headache. A population-based study. Friedman BW., Serrano D., Reed M., Diamond M., Lipton RB. 2009
Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy. Ruger JP., Richter CJ., Spitznagel EL., Lewis LM. 2004
Epidemiologic analysis of an urban, public emergency department's frequent users. Mandelberg JH., Kuhn RE., Kohn MA. 2000
Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Zuckerman S., Shen YC. 2004
Using a Self-Reported Global Health Measure to Identify Patients at High Risk for Future Healthcare Utilization. Blumenthal KJ., Chang Y., Ferris TG., Spirt JC., Vogeli C., Wagle N., Metlay JP. 2017
Are Patients Frequently Readmitted to the Hospital Different from the Other Admitted Patients? Porter M., Quillen D., Fe Agana D., Chacko L., Lynch K., Bielick L., Fu X., Yang Y., Carek PJ. -- Not Found --
Health care costs associated with posttraumatic stress disorder symptoms in women. Walker EA., Katon W., Russo J., Ciechanowski P., Newman E., Wagner AW. 2003
Expenditure variations analysis using residuals for identifying high health care utilizers in a state Medicaid program. Yang C., Delcher C., Shenkman E., Ranka S. 2019
Which patients are persistently high-risk for hospitalization? Chang ET., Piegari R., Wong ES., Rosland AM., Fihn SD., Vijan S., Yoon J. 2019
Identifying Latent Subgroups of High-Risk Patients Using Risk Score Trajectories. Wong ES., Yoon J., Piegari RI., Rosland AM., Fihn SD., Chang ET. 2018
Applying Sequential Analytic Methods to Self-Reported Information to Anticipate Care Needs. Bayliss EA., Powers JD., Ellis JL., Barrow JC., Strobel M., Beck A. 2016
Identifying subgroups of complex patients with cluster analysis. Newcomer SR., Steiner JF., Bayliss EA. 2011
"It's Like Riding Out the Chaos": Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU). Chan B., Hulen E., Edwards S., Mitchell M., Nicolaidis C., Saha S. 2019
What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Doran KM., Raven MC., Rosenheck RA. 2013
Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. Raven MC., Billings JC., Goldfrank LR., Manheimer ED., Gourevitch MN. 2009
Drivers of preventable high health care utilization: a qualitative study of patient, physician and health system leader perspectives. Das LT., Kaushal R., Garrison K., Carrillo V., Grinspan Z., Theis R., Shenkman E., Abramson E. 2019
Improving the management of care for high-cost Medicaid patients. Billings J., Mijanovich T. -- Not Found --
Targeting high utilisers: predictive validity of a screening questionnaire Meek, J. A., Lyon, B. L., May, F. E., Lynch, W. D. 2000
Super-Utilizer Summit: Common Themes from Innovative Complex Care Management Programs. Hasselman, Diane 2013
Clustering inter-arrival time of health care encounters for high utilizers Yang, C., Delcher, C., Shenkman, E., Ranka, S. 2018
A randomized trial of primary intensive care to reduce hospital admissions in patients with high utilization of inpatient services. Sledge WH., Brown KE., Levine JM., Fiellin DA., Chawarski M., White WD., O'connor PG. 2006
The impact of a health education program targeting patients with high visit rates in a managed care organization. Dally DL., Dahar W., Scott A., Roblin D., Khoury AT. -- Not Found --
Effects of a Psychosocial Transitional Care Model on Hospitalizations and Cost of Care for High Utilizers. Weerahandi H., Basso Lipani M., Kalman J., Sosunov E., Colgan C., Bernstein S., Moskowitz AJ., Egorova N. 2015
Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users. Capp R., Misky GJ., Lindrooth RC., Honigman B., Logan H., Hardy R., Nguyen DQ., Wiler JL. 2017
The impact of tailored intervention services on charges and mortality for adult super-utilizers. Durfee J., Johnson T., Batal H., Long J., Rinehart D., Everhart R., Oronce CI., Douglas I., Moore K., Atherly A. 2018
The Economic Impact of Intensive Care Management for High-Cost Medically Complex Patients: An Evaluation of New Mexico's Care One Program. Horn BP., Crandall C., Moffett M., Hensley M., Howarth S., Binder DS., Sklar D. 2016
An emergency room decision-support program that increased physician office visits, decreased emergency room visits, and saved money. Navratil-Strawn JL., Hawkins K., Wells TS., Ozminkowski RJ., Hartley SK., Migliori RJ., Yeh CS. 2014
Reducing utilization by uninsured frequent users of the emergency department: combining case management and drop-in group medical appointments. Crane S., Collins L., Hall J., Rochester D., Patch S. -- Not Found --
Evaluation of care management for the uninsured. Shah R., Chen C., O'Rourke S., Lee M., Mohanty SA., Abraham J. 2011
The effects of a community-based partnership, Project Access Dallas (PAD), on emergency department utilization and costs among the uninsured. DeHaven M., Kitzman-Ulrich H., Gimpel N., Culica D., O'Neil L., Marcee A., Foster B., Biggs M., Walton J. 2012
Effects of team care of frequent attenders on patients and physicians. Adam P., Brandenburg DL., Bremer KL., Nordstrom DL. 2010
Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Shumway M., Boccellari A., O'Brien K., Okin RL. 2008
Reducing emergency visits in older adults with chronic illness. A randomized, controlled trial of group visits. Coleman EA., Eilertsen TB., Kramer AM., Magid DJ., Beck A., Conner D. -- Not Found --
Randomized trial of a depression management program in high utilizers of medical care. Katzelnick DJ., Simon GE., Pearson SD., Manning WG., Helstad CP., Henk HJ., Cole SM., Lin EH., Taylor LH., Kobak KA. 2000
Impact of Social Needs Navigation on Utilization Among High Utilizers in a Large Integrated Health System: a Quasi-experimental Study. Schickedanz A., Sharp A., Hu YR., Shah NR., Adams JL., Francis D., Rogers A. 2019
Effects of a community-based care management model for super-utilizers. Sevak P., Stepanczuk CN., Bradley KWV., Day T., Peterson G., Gilman B., Blue L., Kranker K., Stewart K., Moreno L. 2018
Integrated, Accountable Care For Medicaid Expansion Enrollees: A Comparative Evaluation of Hennepin Health. Vickery KD., Shippee ND., Menk J., Owen R., Vock DM., Bodurtha P., Soderlund D., Hayward RA., Davis MM., Connett J., Linzer M. 2020
Reducing preventable emergency department utilization and costs by using community health workers as patient navigators. Enard KR., Ganelin DM. -- Not Found --
Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial. Zulman DM., Chang ET., Wong A., Yoon J., Stockdale SE., Ong MK., Rubenstein LV., Asch SM. 2019
Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization. Yoon J., Chang E., Rubenstein LV., Zulman DM., Asch SM. 2018
Health Care Hotspotting - A Randomized, Controlled Trial. Finkelstein A., Zhou A., Taubman S., Doyle J. 2020
Community navigators reduce hospital utilization in super-utilizers. Thompson MP., Podila PSB., Clay C., Sharp J., Bailey-DeLeeuw S., Berkley AJ., Baker BG., Waters TM. 2018
Patient Navigation for Patients Frequently Visiting the Emergency Department: A Randomized, Controlled Trial. Seaberg D., Elseroad S., Dumas M., Mendiratta S., Whittle J., Hyatte C., Keys J. 2017
Evaluation of CMS’s Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration Final Report Katherine L. Kahn, Justin W. Timbie, Mark W. Friedberg, Peter Mendel, Liisa Hiatt, Emily K. Chen, Amii M. Kress, Christine Buttorff, Tara A. Lavelle, Beverly A. Weidmer, Harold D. Green, Mallika Kommareddi, Rosalie Malsberger, Aaron Kofner, Afshin Rastegar, Claude Messan Setodji 2016
Evaluation of the Comprehensive Primary Care Initiative Fourth Annual Report Deborah Peikes, Grace Anglin, Stacy Dale, Erin Fries Taylor, Ann O''Malley, Arkadipta Ghosh, Kaylyn Swankoski, Jesse Crosson, Rosalind Keith, Anne Mutti, Sheila Hoag, Pragya Singh, Ha Tu, Thomas Grannemann, Mariel Finucane, Aparajita Zutshi, Lauren Vollmer, Randall Brown 2018
Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: VillageHealth’s Key to Better Health (KTBH) Nancy McCall, Jerry Cromwell, Carol Urato 2010
Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: Texas Senior Trails (TST) Final Report Nancy McCall, Jerry Cromwell, Carol Urato, Terry Eng 2010
Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: The Health Buddy® Consortium (HBC) Final Report Nancy McCall, Jerry Cromwell, Kevin Smith, Carol Urato 2011
Independent Evaluation of Comprehensive Primary Care Plus (CPC+) First Annual Report Deborah Peikes, Grace Anglin, Mary Harrington, Arkadipta Ghosh, Kristin Geonnotti, Ann O'Malley, Stacy Dale, Sheila Hoag, Dana Petersen, Pragya Singh, Ha Tu, Laura Blue, Sean Orzol, Rosalind Keith, Anne Mutti, Genna Cohen, Tricia Higgins, Laurie Felland, Linda Barterian, Victoria Peebles, Amanda Lechner 2019
Evaluation of the Independence at Home Demonstration: An Examination of the First Four Years Laura Kimmey, Michael Anderson, Valerie Cheh, Evelyn Li, Catherine McLaughlin, Linda Barterian, Jay Crosson, Cara Stepanczuk, Lori Timmins 2019
Evaluation of Health Care Innovation Awards (HCIA): Primary Care Redesign Programs Third Annual Report Greg Peterson, Laura Blue, Lorenzo Moreno, Keith Kranker, Boyd Gilman, Kate Stewart, Sandi Nelson, Kristin Geonnotti, Sheila Hoag, Andrew McGuirk, Ken Peckham 2017
Evaluation of the Extended Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: VillageHealth’s Key to Better Health (KTBH) Final Report Carol Urato, Nancy McCall, Jerry Cromwell, Nancy Lenfestey, Douglas Raeder 2013
Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: Care Level Management (CLM) Final Report Nancy McCall, Jerry Cromwell, Carol Urato, Terry Eng 2010
Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: Massachusetts General Hospital and Massachusetts General Physicians Organization (MGH) Final Report Nancy McCall, Jerry Cromwell, Carol Urato 2010
Patient perceptions of a community-based care coordination system Nora Gimpel, Alice Marcee, Kambria Kennedy, James Walton, Shannon Lee, Mark J DeHaven 2010
Not Entered Yet - -
Passive social health surveillance and inpatient readmissions. Emechebe N., Lyons Taylor P., Amoda O., Pruitt Z. 2019
Distinct subgroups of emergency department frequent users: A latent class analysis. Birmingham LE., Cheruvu VK., Frey JA., Stiffler KA., VanGeest J. 2020
Factors Associated With Geriatric Frequent Users of Emergency Departments. Castillo EM., Brennan JJ., Howard J., Hsia RY., Chalmers C., Chan TC., Ko KJ. 2019
Assessment of utilization efficiency using machine learning techniques: A study of heterogeneity in preoperative healthcare utilization among super-utilizers. Hyer JM., Paredes AZ., White S., Ejaz A., Pawlik TM. 2020
Frequent Emergency Department Users: Focusing Solely On Medical Utilization Misses The Whole Person. Kanzaria HK., Niedzwiecki M., Cawley CL., Chapman C., Sabbagh SH., Riggs E., Chen AH., Martinez MX., Raven MC. 2019
Persistence of High-Need Status Over Time Among Fee-for-Service Medicare Beneficiaries. Keeney T., Joyce NR., Meyers DJ., Mor V., Belanger E. 2020
Medication nonadherence, mental health, opioid use, and inpatient and emergency department use in super-utilizers. Surbhi S., Graetz I., Wan JY., Gatwood J., Bailey JE. 2020
Food insecurity, healthcare utilization, and high cost: a longitudinal cohort study. Berkowitz SA., Seligman HK., Meigs JB., Basu S. 2018
Characteristics And Spending Patterns Of Persistently High-Cost Medicare Patients. Figueroa JF., Zhou X., Jha AK. 2019
High-Cost Patients: Hot-Spotters Don't Explain the Half of It. Lee NS., Whitman N., Vakharia N., Taksler GB., Rothberg MB. 2017
Subgroups of High-Cost Medicare Advantage Patients: an Observational Study. Powers BW., Yan J., Zhu J., Linn KA., Jain SH., Kowalski JL., Navathe AS. 2019
Use of Latent Class Analysis and k-Means Clustering to Identify Complex Patient Profiles. Grant RW., McCloskey J., Hatfield M., Uratsu C., Ralston JD., Bayliss E., Kennedy CJ. 2020
The Role of Social and Clinical Determinants in the Frequent Utilization of Emergency Departments Mohammed and Moazam Ali 2018
Service Delivery and Quality of Care for Individuals with Mental Illness Gopalan 2017
Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population. Sandberg SF., Erikson C., Owen R., Vickery KD., Shimotsu ST., Linzer M., Garrett NA., Johnsrud KA., Soderlund DM., DeCubellis J. 2014
Patient perceptions of a community-based care coordination system. Gimpel N., Marcee A., Kennedy K., Walton J., Lee S., DeHaven MJ. 2010
Economic outcomes of insurer-led care management for high-cost Medicaid patients. Harrison JM., Oganisian A., Grande DT., Mitra N., Chhabra M., Chaiyachati KH. 2020
Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured, Frequent ED Users: A Randomized Controlled Trial. Kelley L., Capp R., Carmona JF., D'Onofrio G., Mei H., Cobbs-Lomax D., Ellis P. 2020
Impact of complex care management on spending and utilization for high-need, high-cost Medicaid patients. Powers BW., Modarai F., Palakodeti S., Sharma M., Mehta N., Jain SH., Garg V. 2020
Integrated Home- and Community-Based Services Improve Community Survival Among Independence at Home Medicare Beneficiaries Without Increasing Medicaid Costs. Valluru G., Yudin J., Patterson CL., Kubisiak J., Boling P., Taler G., De Jonge KE., Touzell S., Danish A., Ornstein K., Kinosian B. 2019
A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services. Raven MC., Niedzwiecki MJ., Kushel M. 2020
Resource-limited, collaborative pilot intervention for chronically homeless, alcohol-dependent frequent emergency department users. McCormack RP., Hoffman LF., Wall SP., Goldfrank LR. 2013
ED-based care coordination reduces costs for frequent ED users. Lin MP., Blanchfield BB., Kakoza RM., Vaidya V., Price C., Goldner JS., Higgins M., Lessenich E., Laskowski K., Schuur JD. 2017
A randomized controlled trial of intensive care management for disabled Medicaid beneficiaries with high health care costs. Bell JF., Krupski A., Joesch JM., West II., Atkins DC., Court B., Mancuso D., Roy-Byrne P. 2015
Evaluation of the Independence at Home Demonstration: An Examination of the First Five Years Kimmey 2020
Independent Evaluation of Comprehensive Primary Care Plus (CPC+): Second Annual Report Anglin 2020




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