Interventions for Frequently Hospitalized Patients and Their Effect on Outcomes: A Systematic Review

Alexandra Goodwin
Bruce L. Henschen
Linda C. O'Dwyer
Natasha Nichols
Kevin J. O'Leary
Journal Article
December 2018

This resource reviews interventions for frequently hospitalized patients and assesses the effectiveness of these interventions.

  • Health care organizations have begun to implement interventions that supplement or redesign care for frequently hospitalized patients.
  • In the nine studies selected, the majority of interventions added direct services or support – most commonly, a social worker – to standard care. Other common themes included caring for patients across settings and incorporating information technology into workflows.
  • Overall, studies reported mixed results. While low-quality studies found reductions in hospital use over time, higher quality studies found similar reductions in utilization between the intervention and control groups.
  • Care fragmentation probably plays an important role in the risk for readmissions in this population; interventions that address factors across the continuum of care may be more likely to succeed.
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Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • What interventions are health care systems using to reduce hospitalizations for frequently hospitalized patients?
  • How effective are these interventions?
  • What steps are needed going forward?
Level of Evidence
What does this mean?