Reducing Utilization of Hospital Resources through Implementing Outpatient Follow-up in a Rural Setting




Calcagno, Alexa
Johnson, Jeremy
Gibson, John
Hadley, Lesca


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Purpose: Will increased outpatient follow-up with patients having multiple chronic conditions lead to decreased utilization of hospital resources? About 15% of the U.S. population qualifies for Medicare, the majority of which have chronic conditions requiring regular management. One Medicare component, the Chronic Care Management (CCM) Program, allows for establishment of a comprehensive care plan in patients with two or more chronic conditions at risk of death or functional decline. Initiated at Graham Healthcare and Urgent Care in Graham, Texas in January 2020, the goal of CCM is to encourage outpatient management of chronic conditions and reduce utilization of emergency room (ER) or inpatient services. Methods: The target population was 24 clinic patients enrolled in CCM in January or February of 2020. The number of ER visits, hospital admissions, and clinic visits of each patient in the 7 months before enrollment were compared to the number in the 7 months after enrollment. Results: The number of ER visits and hospital admissions before enrollment compared to the number after enrollment decreased by 11.8%. However, the number of clinic visits did not change before and after enrollment. Conclusion: If a larger sample size of patients were tracked over a longer time frame, it is likely the number of clinic visits would increase, and the number of ER visits and hospitalizations would continue to decrease. Therefore, the goal is to continue growth of enrollment in CCM and to implement a follow-up protocol to enhance efficacy of CCM services and advanced-care planning.