Patients who are frequently hospitalized account for a disproportionate amount of health care spending in the United States. The Comprehensive Care Program (CCP) studies whether changes to where and how doctors see patients can reduce spending and improve care for this high-risk group.

The CCP initiative is a randomized study started in 2012 with the aim of testing novel care delivery systems for improving the quality and reducing the cost of health care. The current standard for most patients is to be seen in an outpatient setting by a doctor who knows their health history and sees them regularly, but if they are admitted to the hospital, they receive care from a different doctor they may not know.

Working with a $6.1 million grant from the Center for Medicare & Medicaid Innovation, the CCP study tests whether having a single physician see patients at high risk of hospitalization in both inpatient and outpatient settings can improve outcomes and lower costs. The study’s hypothesis is that this improved continuity of care will strengthen the relationship between doctor and patient and reduce unnecessary emergency department visits, hospital admissions, and readmissions.

Dr. Meltzer partnered with the CRI to create the technological infrastructure required for this project. Our applications development team developed a custom dashboard and alert system that serves as a central location for CCP staff and physicians to record study information on patients and integrate this information with data from electronic medical records. The dashboard is combined with a notification system that sends pages and emails to the appropriate CCP physicians and staff when a patient enrolled to the CCP protocol visits the emergency department or is admitted to the hospital. The infrastructure the CRI developed for this project marked the first time clinicians within UCM were able to receive such alerts.

Since its deployment in January 2013, the CCP dashboard has handled more than 800 patients and 19,000 encounters and generated more than 15,000 alerts.