I read an interesting article in the Journal of Hospital Medicine called, “The highest utilizers of care: individualized care plans to coordinate care, improve health care service utilization, and reduce costs at an academic tertiary care center.” Since we are in an academic tertiary care center and concerned about cost, I thought the article might have some concepts worth considering for Texas Tech Physicians. It turned out to be a good article.

It describes a study that looked at 24 patients who were the highest utilizers of health care services and for whom an individualized care plan was developed in hopes of improving the patients’ quality of care. The researchers wanted to see if the individualized care plan would make a difference. The plans were developed collaboratively and with time to thoughtfully consider the patients’ need in advance, rather than creating a plan in the “spur of the moment” when one of the patients presented in the emergency center. They then loaded these plans into the electronic health record, so they were available to all who needed them before treating the patient. The professionals doing this came from multidisciplinary backgrounds and included numerous doctors and nurses from several specialties, as well as social workers, pharmacists and mental health experts.

As a result, money was saved, and health care for these patients improved through a more thoughtful, long-term approach to their care and good communication among the team of people who developed the care plans. This idea is exciting because it fits with the Institute for Healthcare Improvement’s Triple Aim framework that describes an a three-dimensional approach to optimizing health system performance that includes:

· Improving the patient experience through quality care
· Improving the health of populations
· Reducing the per capita cost of health care

What is interesting about this study is that making a difference required providers to change their approach and work interprofessionally according to a shared plan. Obviously, not all patients will take our advice on smoking cessation, weight control, medication usage and so forth, but we can coordinate better and thereby utilize the strength of the entire health sciences team.
“E Pluribus Unum,” the phrase on our money, is Latin for "out of many, one." Maybe out of the many experts in this building, we could, in a sense, become one in optimizing care to our patients.