The Impact of an Integrated Model of Care for the Frequent User Population in Ontario

 ‘Frequent users’ of the healthcare system are patients who experience multiple hospital admissions and emergency department visits. An Ontario study (Wodchis, Austin, & Henry, 2016) documented that 5% of Ontario citizens consume 67% of health system resources due to high prevalence of hospitalizations and emergency services utilization. Yet, health organizations have no current way to identify patients who are frequent users as they seek services and care. Consequently, if frequent users cannot be identified as they enter Ontario hospitals, clinician teams are unable to design clinical care approaches to better support these patients to remain healthy in the community and reduce their frequent need for hospital services.

To overcome this substantial challenge, a community hospital adopted a new technology. The software application was connected to the hospital information system to cross reference patient information to identify patients accessing the hospital system more than three times in the previous year. Once a frequent user was identified, the community hospital team worked with each patient to create an individualized and integrated model of care. Case managers and the primary care team were mobilized to partner with the patient and their family to co-create care plans that focused on personal goals for wellness and quality of life. Key features of the individualized, integrated model of care in the community included the following: high level of patient and family engagement in setting goals and planning care focusing on the whole person with quality of life as a central goal of care; leveraging existing strengths of clinical care in the community; and engagement of primary care physicians as the lead coordinator of care with the support of intensive case management.

This study created the evidence of impact of the community hospital’s innovative approach to identify and care for frequent users of the health system. Use of the individualized, integrated model of case management and the impact the model achieved on patient outcomes was documented including patient admissions to hospital, and frequency of visits to emergency departments for care. The study involved interviews with primary care teams, hospital case managers, and patients to examine the effectiveness of the software and the individualized, integrated case management model on patient outcomes and quality of work-life for clinical teams.

The software identified that frequent user patients change over time: each month there were new frequent patients approached to participate in the integrated care model, and patients whose integrated care resulted no further need to access emergency care or hospitalization at the community hospital. The software tool identified the frequent user status of a patient, providing information to better understand the dynamic and changing needs of the frequent user population. Frequent user patient profiles were characterized by multiple chronic conditions, low income (< $20,000/year), mental health challenges in over 50% of cases, and high school education or less in the majority of these patients. The individualized, integrated model of care focused on ensuring the right care provider was offering services when needed, and care decisions were led by the primary care physician. 

The early outcomes of the integrated care model documented statistically significant reductions in hospital days by 40%, and reduced ED visits by these patients by 40%. The model enabled networking and communication among clinicians across primary care, community care, and hospital settings. The integrated model of care focused on helping patients to achieve their personal health goals. The clinician teams partnered with patients to help them self-manage their health conditions to achieve greater health and wellness, and reduce their reliance on emergency care services.


Wodchis, W.P., Austin, P.C., & Henry, D.A. (2016). A 3-year study of high-cost users of health care. CMAJ. doi: 10.1503/cmaj.150064



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