Results of Literature Searches

The electronic search, grey literature, and reference mining identified 2,923 citations. After title and abstract screening, 873 citations were retrieved for full-text review. A total of 110 studies (117 articles) met eligibility criteria. A total of 110 studies (117 articles) were included in the analyses.

Description of Included Studies

For KQ 1, we identified 60 studies (61 articles), of which 33 were cross sectional, 10 latent class, 11 predictive, and 6 qualitative.^16–76

For KQ 2, we identified we identified 48 studies (51 articles).^{12, 17, 22, 27–29, 31, 49, 53, 55, 58, 61, 62, 77–114} As for unique KQ 2 includes, we identified 10 studies (10 articles).^{12, 78, 91, 93, 94, 104–106, 113, 114}

For KQ 3, we identified 19 trials and 21 observational studies (46 articles). Five RCTs were assessed as having low risk of bias, and 14 RCTs (15 articles) were assessed as having some concerns for bias,^{79–82, 84, 86, 87, 90, 96, 97, 99, 108–112, 115–118} No observational studies were assessed as having low risk of bias, 13 observational studies (17 articles) were assessed as having some concerns for bias, and eight observational studies (9 articles) were assessed as having high risk of bias.^{83, 85, 88, 92, 95, 98, 100–103, 107, 119–133}

Figure B-1Article flow diagram

Note: The sum of the number of studies per KQ exceeds the total number of studies because some studies were applicable to multiple KQs.

KQ = Key Question.

List of Excluded Studies

• X1: Ineligible Population
• X2: Ineligible Intervention
• X3: Ineligible Comparator
• X4: Ineligible Outcome
• X5: Ineligible Time Frame
• X6: Setting/Country
• X7: Secondary Review of Literature or Interventions
• X8: Not Original Research for KQ 3
• X9: Study Design
• X10: Not English
• X11: Irretrievable
• X12: Duplicate

1.

Magellan initiative targets high utilizers in private plans. Mental Health Weekly. 2000;10(32):1. PMID: 3493535. Exclusion Code: X1.

2.

Hand-held devices ease burden of behavioral health assessment. Dis Manag Advis. 2002;8(10):152–6, 45. Exclusion Code: X1. [PubMed: 12422804]

3.

Medicaid best buys: improving care management for high-need, high-cost beneficiaries. Hamilton, N.J.: Center for Health Care Strategies, Inc.; 2008. Exclusion Code: X4.

4.

Medicaid best buys: critical strategies to focus on high-need, high-cost beneficiaries. Hamilton, N.J.: Center for Health Care Strategies, Inc.; 2010. Exclusion Code: X1.

5.

Building the national care service. Norwich: Great Britain Stationary Office; 2010. Exclusion Code: X1.

6.

ED diversion: multidisciplinary approach engages high utilizers, helps them better navigate the health care system. ED management: the monthly update on emergency department management. 2011;23(11):127–30. Exclusion Code: X1. [PubMed: 22043590]

7.

CM program keeps high utilizers out of hospital. Hosp Case Manag. 2012;20(7):108–9. PMID: 104470969. Language: English. Entry Date: 20120711. Revision Date: 20150711. Publication Type: Journal Article. Journal Subset: Nursing. Exclusion Code: X1. [PubMed: 22808541]

8.

Hospitals collaborate to reduce ED overuse. Hosp Case Manag. 2012 Oct;20(10):151–3. PMID: 23084509. Exclusion Code: X1. [PubMed: 23091842]

9.

Patient navigation for Medicaid frequent ED users. Yale University. 2013. https://www​.cochranelibrary​.com/central/doi/10​.1002/central/CN-01579091/full. PMID: CN-01579091. Exclusion Code: X4.

10.

Identifying high utilizers of surgical care after colectomy. J Surg Res. 2014;186(2):495-. doi: 10.1016/j.jss.2013.11.036. PMID: 93484679. Exclusion Code: X1. [CrossRef]

11.

Programs focusing on high-need, high-cost populations. [Trenton, N.J.]: Center for Health Care Strategies, Inc.; 2016. Exclusion Code: X1.

12.

Understanding the needs of different types of high-need patients and their caregivers. Commonwealth Fund; 2019. Exclusion Code: X1.

13.

Community Care For High-Need Patients. Health Aff (Millwood). 2019 Jun;38(6):892–3. doi: 10.1377/hlthaff.2019.00473. PMID: 31454082. Exclusion Code: X8. [PubMed: 31158014] [CrossRef]

14.

Evaluation of a Multidisciplinary Care Coordination Program for Frequent Users of the Emergency Department. Prof Case Manag. 2019 Sep/Oct;24(5):E1–e2. doi: 10.1097/ncm.0000000000000388. PMID: 30593912. Exclusion Code: X1. [PubMed: 31369485] [CrossRef]

15.

Extreme consumers of health care: patterns of care utilization in patients with multiple chronic conditions admitted to a novel integrated clinic. Journal of multidisciplinary healthcare. 2019;12:1075–83. doi: 10.2147/JMDH.S214770. PMID: CN-02136481. Exclusion Code: X6. [PMC free article: PMC6935286] [PubMed: 31920324] [CrossRef]

16.

Assertive Community Treatment for Alcohol Misuse Disorder Patients Who Are High Utilizers of Emergency Department Services (ARFA). Khoo Teck Puat Hospital. Jun 25, 2020. Exclusion Code: X11.

17.

Ackroyd-Stolarz S, Read Guernsey J, Mackinnon NJ, et al. The association between a prolonged stay in the emergency department and adverse events in older patients admitted to hospital: a retrospective cohort study. BMJ Qual Saf. 2011 Jul;20(7):564–9. doi: 10.1136/bmjqs.2009.034926. PMID: 21776300. Exclusion Code: X1. [PubMed: 21209130] [CrossRef]

18.

Acosta AM, Lima MA. Frequent users of emergency services: associated factors and reasons for seeking care. Rev Lat Am Enfermagem. 2015 Feb–Apr;23(2):337–44. doi: 10.1590/0104-1169.0072.2560. PMID: 26240244. Exclusion Code: X1. [PMC free article: PMC4459009] [PubMed: 26039306] [CrossRef]

19.

Adler-Milstein J. Assessing the impact of Medicare advantage on high-cost, high-need beneficiaries and exploring an intervention to improve outcomes. Michigan: Commonwealth Fund; 2017. Exclusion Code: X1.

20.

Agarwal G, Lee J, McLeod B, et al. Social factors in frequent callers: a description of isolation, poverty and quality of life in those calling emergency medical services frequently. BMC Public Health. 2019 Jun 3;19(1):684. doi: 10.1186/s12889-019-6964-1. PMID: 31277151. Exclusion Code: X1. [PMC free article: PMC6547509] [PubMed: 31159766] [CrossRef]

21.

Agarwal G, McDonough B, Angeles R, et al. Rationale and methods of a multicentre randomised controlled trial of the effectiveness of a Community Health Assessment Programme with Emergency Medical Services (CHAP-EMS) implemented on residents aged 55 years and older in subsidised seniors’ housing buildings in Ontario, Canada. BMJ Open. 2015 Jun 11;5(6):e008110. doi: 10.1136/bmjopen-2015-008110. PMID: 26206441. Exclusion Code: X1. [PMC free article: PMC4466604] [PubMed: 26068514] [CrossRef]

22.

Agterberg J, Zhong F, Crabb R, et al. Cluster analysis application to identify groups of individuals with high health expenditures. Health Services & Outcomes Research Methodology. 2020;20(2/3):140–82. doi: 10.1007/s10742-020-00214-8. PMID: 145263707. Exclusion Code: X4. [CrossRef]

23.

Aird P, Hansford P, O’Brien R, et al. The impact of frequent users of OOH services. Br J Gen Pract. 2001 Jun;51(467):494–5. PMID: 15094029. Exclusion Code: X1. [PMC free article: PMC1314038] [PubMed: 11407062]

24.

al Yousif N, Hussain HY, El Din Mhakluf MM. Health care services utilization and satisfaction among elderly in Dubai, UAE and some associated determinants. Middle East Journal of Age & Ageing. 2014;11(3):25–33. PMID: 96513555. Exclusion Code: X1.

25.

Alderwick H, Hood-Ronick CM, Gottlieb LM. Medicaid Investments To Address Social Needs In Oregon And California. Health Aff (Millwood). 2019 May;38(5):774–81. doi: 10.1377/hlthaff.2018.05171. PMID: 31059356. Exclusion Code: X1. [PubMed: 31059356] [CrossRef]

26.

Alexander Billioux KV, Susan Anthony, Dawn Alley. Standardized Screening for Health-Related Social Needs in Clinical Settings The Accountable Health Communities Screening Tool. 2017. Exclusion Code: X2.

27.

Alghanim SA, Alomar BA. Frequent use of emergency departments in Saudi public hospitals: implications for primary health care services. Asia Pac J Public Health. 2015 Mar;27(2):Np2521–30. doi: 10.1177/1010539511431603. PMID: 25547107. Exclusion Code: X1. [PubMed: 22186384] [CrossRef]

28.

Allen CG, Escoffery C, Satsangi A, et al. Strategies to improve the integration of community health workers into health care teams: “a little fish in a big pond”. Prev Chronic Dis. 2015 Sep 17;12:E154. doi: 10.5888/pcd12.150199. PMID: 26875022. Exclusion Code: X1. [PMC free article: PMC4576500] [PubMed: 26378900] [CrossRef]

29.

Althaus F, Paroz S, Hugli O, et al. Effectiveness of interventions targeting frequent users of emergency departments: a systematic review. Ann Emerg Med. 2011 Jul;58(1):41–52 e42. doi: 10.1016/j.annemergmed.2011.03.007. PMID: 21689565. Exclusion Code: X1. [PubMed: 21689565] [CrossRef]

30.

Althaus F, Stucki S, Guyot S, et al. Characteristics of highly frequent users of a Swiss academic emergency department: a retrospective consecutive case series. Eur J Emerg Med. 2013 Dec;20(6):413–9. doi: 10.1097/MEJ.0b013e32835e078e. PMID: 25139183. Exclusion Code: X1. [PubMed: 23337095] [CrossRef]

31.

Altman D. A small group of patients account for a whole lot of spending. Axios. 2019. https://www​.axios.com​/drug-prices-health-care-costs-spending-employers-63a65abc-0148-4f98-bd39-b30e4d3c9caf.html. Exclusion Code: X7.

32.

Alvarado LP. Mobile psychiatric services decrease readmission rates among high utilizers of emergency treatment services: ProQuest Information & Learning; 2021. Exclusion Code: X3.

33.

Amarasingham R, Xie B, Karam A, et al. Using community partnerships to integrate health and social services for high-need, high-cost patients. Commonwealth Fund. 2018. https://www​.commonwealthfund​.org/publications​/issue-briefs/2018​/jan/using-community-partnerships-integrate-health-and-social. Exclusion Code: X1. [PubMed: 29320140]

34.

Anderson DR, Mangen DJ, Grossmeier JJ, et al. Comparing alternative methods of targeting potential high-cost individuals for chronic condition management. J Occup Environ Med. 2010 Jun;52(6):635–46. doi: 10.1097/JOM.0b013e3181e31792. PMID: 15175823. Exclusion Code: X9. [PubMed: 20523235] [CrossRef]

35.

Anderson GM. Program delivery for high-needs, high-cost populations: international perspectives on the way forward, phase I. University of Toronto, Faculty of Medicine, Institute of Health Policy, Management and Evaluation 2017. https://hsrproject​.nlm​.nih.gov/view_hsrproj_record/20191229. Exclusion Code: X7.

36.

Andrews G, Sunderland M. Telephone case management reduces both distress and psychiatric hospitalization. Aust N Z J Psychiatry. 2009 Sep;43(9):809–11. doi: 10.1080/00048670903107617. PMID: 17515738. Exclusion Code: X1. [PubMed: 19670053] [CrossRef]

37.

Angelelli J, Gifford D, Intrator O, et al. Access to postacute nursing home care before and after the BBA (Balanced Budget Act). Health Aff (Millwood). 2002 Sep–Oct;21(5):254–64. doi: 10.1377/hlthaff.21.5.254. PMID: 12450957. Exclusion Code: X1. [PubMed: 12224890] [CrossRef]

38.

Armstrong G, De Marchis E, Mix R, et al. Using Social Needs Screening and Patient Feedback for Complex Care. National Center for Complex Health and Social Needs; 2020. alcomplex​.care/research-policy​/resources​/webinars/using-social-needs-screening-and-patient-feedback-for-complex-care​/2020. Exclusion Code: X1.

39.

Avila J, Jupiter D, Chavez-MacGregor M, et al. High-Cost Hospitalizations Among Elderly Patients With Cancer. J Oncol Pract. 2019 May;15(5):e447–e57. doi: 10.1200/jop.18.00706. PMID: 30354887. Exclusion Code: X1. [PubMed: 30946640] [CrossRef]

40.

Azogil-López LM, Pérez-Lázaro JJ, Ávila-Pecci P, et al. Effectiveness of a new model of telephone derivation shared between primary care and hospital care. Atencion primaria / Sociedad Espanola de Medicina de Familia y Comunitaria. 2019;51(5):278–84. doi: 10.1016/j.aprim.2018.02.006. PMID: CN-02133656. Exclusion Code: X10. [PMC free article: PMC6836997] [PubMed: 29699717] [CrossRef]

41.

Bagnall AM, South J, Forshaw MJ, et al. Self-care in primary care: findings from a longitudinal comparison study. Prim Health Care Res Dev. 2013 Jan;14(1):29–39. doi: 10.1017/s1463423612000199. PMID: 24568286. Exclusion Code: X1. [PubMed: 22717510] [CrossRef]

42.

Bailey JE, Surbhi S, Wan JY, et al. Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study. J Gen Intern Med. 2019 Sep;34(9):1815–24. doi: 10.1007/s11606-019-05082-8. PMID: 32245460. Exclusion Code: X1. [PMC free article: PMC6712187] [PubMed: 31270786] [CrossRef]

43.

Baker JM, Grant RW, Gopalan A. A systematic review of care management interventions targeting multimorbidity and high care utilization. BMC Health Serv Res. 2018 Jan 30;18(1):65. doi: 10.1186/s12913-018-2881-8. PMID: 29382327. Exclusion Code: X1. [PMC free article: PMC5791200] [PubMed: 29382327] [CrossRef]

44.

Balaban RB, Zhang F, Vialle-Valentin CE, et al. Impact of a Patient Navigator Program on Hospital-Based and Outpatient Utilization Over 180 Days in a Safety-Net Health System. J Gen Intern Med. 2017 Sep;32(9):981–9. doi: 10.1007/s11606-017-4074-2. PMID: 28523476. Exclusion Code: X1. [PMC free article: PMC5570741] [PubMed: 28523476] [CrossRef]

45.

Balfour ME, Zinn TE, Cason K, et al. Provider-payer partnerships as an engine for continuous quality improvement. Psychiatr Serv. 2018;69(6):623–5. doi: 10.1176/appi.ps.201700533. PMID: 129890973. Language: English. Entry Date: In Process. Revision Date: 20180609. Publication Type: Article. Journal Subset: Biomedical. Exclusion Code: X1. [PubMed: 29493418] [CrossRef]

46.

Barker SL, Maguire NJ, Das S, et al. Values-Based Interventions in Patient Engagement for Those with Complex Needs. Popul Health Manag. 2020;23(2):140–5. doi: 10.1089/pop.2019.0084. PMID: 142272277. Language: English. Entry Date: 20200320. Revision Date: 20200324. Publication Type: Article. Exclusion Code: X1. [PubMed: 31503526] [CrossRef]

47.

Barsky AJ, Ahern DK, Bauer MR, et al. A randomized trial of treatments for high-utilizing somatizing patients. J Gen Intern Med. 2013;28(11):1396–404. doi: 10.1007/s11606-013-2392-6. PMID: CN-00909578. Exclusion Code: X1. [PMC free article: PMC3797340] [PubMed: 23494213] [CrossRef]

48.

Bauman CA, Fillingham J, Keely-Dyck E, et al. An approach to interprofessional management of complex patients: a case report. Journal of the Canadian Chiropractic Association. 2019;63(2):119–25. PMID: 138594442. Language: English. Entry Date: 20190916. Revision Date: 20190926. Publication Type: Article. Exclusion Code: X6. [PMC free article: PMC6743649] [PubMed: 31564750]

49.

Bayliss EA, Ellis JL, Powers JD, et al. Using self-reported data to segment older adult populations with complex care needs. EGEMS (Wash DC). 2019 Apr 12;7(1):12. doi: 10.5334/egems.275. PMID: 31065556. Exclusion Code: X1. [PMC free article: PMC6484372] [PubMed: 31065556] [CrossRef]

50.

Beach SR, Schulz R, Friedman EM, et al. Adverse Consequences of Unmet Needs for Care in High-Need/High-Cost Older Adults. J Gerontol B Psychol Sci Soc Sci. 2020 Jan 14;75(2):459–70. doi: 10.1093/geronb/gby021. PMID: 30522388. Exclusion Code: X3. [PubMed: 29471360] [CrossRef]

51.

Becker T, Steffen S, Puschner B. Discharge planning, an intervention study - and where to go next? Eur Psychiatry. 2011;26. doi: 10.1016/S0924-9338(11)73744-0. PMID: CN-01782093. Exclusion Code: X1. [CrossRef]

52.

Bedoya P, Neuhausen K, Dow AW, et al. Student Hotspotting: Teaching the Interprofessional Care of Complex Patients. Acad Med. 2018 Jan;93(1):56–9. doi: 10.1097/acm.0000000000001822. PMID: 28700461. Exclusion Code: X1. [PubMed: 28700461] [CrossRef]

53.

Beesley VL, Smithers BM, O’Rourke P, et al. Variations in supportive care needs of patients after diagnosis of localised cutaneous melanoma: a 2-year follow-up study. Support Care Cancer. 2017 Jan;25(1):93–102. doi: 10.1007/s00520-016-3378-9. PMID: 26389982. Exclusion Code: X1. [PubMed: 27562298] [CrossRef]

54.

Beima-Sofie K, Begnel ER, Golden MR, et al. “It’s Me as a Person, Not Me the Disease”: Patient Perceptions of an HIV Care Model Designed to Engage Persons with Complex Needs. AIDS Patient Care STDS. 2020 Jun;34(6):267–74. doi: 10.1089/apc.2019.0310. PMID: 31670693. Exclusion Code: X1. [PMC free article: PMC7262637] [PubMed: 32484744] [CrossRef]

55.

Bélanger E, McHugh J, Meyers DJ, et al. Characteristics of Top-Performing Hospitals Caring for High-Need Medicare Beneficiaries. Popul Health Manag. 2020;23(4):313–8. doi: 10.1089/pop.2019.0145. PMID: 144824249. Language: English. Entry Date: 20200813. Revision Date: 20200813. Publication Type: Article. Exclusion Code: X1. [PubMed: 31816254] [CrossRef]

56.

Bellon JA, Rodriguez-Bayon A, Luna JD, et al. Successful GP intervention with frequent attenders in primary care: randomised controlled trial. Br J Gen Pract. 2008 May;58(550):324–30. doi: 10.3399/bjgp08X280182. PMID: WOS:000256654700006. Exclusion Code: X1. [PMC free article: PMC2435670] [PubMed: 18482486] [CrossRef]

57.

Bergenstal TD, Reitsema J, Heppner P, et al. Personalized Care Plans: Are They Effective in Decreasing ED Visits and Health Care Expenditure Among Adult Super-Utilizers? J Emerg Nurs. 2020 Jan;46(1):83–90. doi: 10.1016/j.jen.2019.09.001. PMID: 32750132. Exclusion Code: X1. [PubMed: 31685338] [CrossRef]

58.

Bergeron P, Courteau J, Vanasse A. Proximity and emergency department use: multilevel analysis using administrative data from patients with cardiovascular risk factors. Can Fam Physician. 2015 Aug;61(8):e391–7. PMID: 26747456. Exclusion Code: X1. [PMC free article: PMC4541449] [PubMed: 26505061]

59.

Bergh H, Marklund B. Characteristics of frequent attenders in different age and sex groups in primary health care. Scand J Prim Health Care. 2003 Sep;21(3):171–7. doi: 10.1080/02813430310001149. PMID: WOS:000185314100010. Exclusion Code: X1. [PubMed: 14531510] [CrossRef]

60.

Berghofer A, Hartwich A, Bauer M, et al. Efficacy of a systematic depression management program in high utilizers of primary care: a randomized trial. BMC Health Serv Res. 2012 Sep 3;12:298. doi: 10.1186/1472-6963-12-298. PMID: 25527472. Exclusion Code: X1. [PMC free article: PMC3489593] [PubMed: 22943609] [CrossRef]

61.

Berghöfer A, Roll S, Bauer M, et al. Screening for depression and high utilization of health care resources among patients in primary care. Community Ment Health J. 2014;50(7):753–8. doi: 10.1007/s10597-014-9700-4. PMID: 103896118. Language: English. Entry Date: 20140924. Revision Date: 20151001. Publication Type: Journal Article. Exclusion Code: X1. [PubMed: 24449430] [CrossRef]

62.

Berkowitz SA. Capsule Commentary on Schickedanz et al., Impact of Social Needs Navigation on Utilization Among High-Utilizers in a Large Integrated Health System: a Quasi-Experimental Study. JGIM: Journal of General Internal Medicine. 2019;34(11):2582-. doi: 10.1007/s11606-019-05296-w. PMID: 139599661. Exclusion Code: X8. [PMC free article: PMC6848514] [PubMed: 31452028] [CrossRef]

63.

Bertoli-Avella AM, Haagsma JA, Van Tiel S, et al. Frequent users of the emergency department services in the largest academic hospital in the Netherlands: a 5-year report. Eur J Emerg Med. 2017 Apr;24(2):130–5. doi: 10.1097/mej.0000000000000314. PMID: 28863030. Exclusion Code: X1. [PubMed: 26287805] [CrossRef]

64.

Bieler G, Paroz S, Faouzi M, et al. Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system. Acad Emerg Med. 2012 Jan;19(1):63–8. doi: 10.1111/j.1553-2712.2011.01246.x. PMID: 21701913. Exclusion Code: X1. [PubMed: 22221292] [CrossRef]

65.

Bilazarian A. High-need high-cost patients: A Concept Analysis. Nurs Forum. 2020. doi: 10.1111/nuf.12500. Exclusion Code: X1. [PubMed: 32851669] [CrossRef]

66.

Billett J, Cowie MR, Gatzoulis MA, et al. Comorbidity, healthcare utilisation and process of care measures in patients with congenital heart disease in the UK: cross-sectional, population-based study with case-control analysis. Heart. 2008 Sep;94(9):1194–9. doi: 10.1136/hrt.2007.122671. PMID: 17610000. Exclusion Code: X1. [PubMed: 17646191] [CrossRef]

67.

Bischoff RJ, Hollist CS, Patterson J, et al. Providers’ perspectives on troublesome overusers of medical services. Families, Systems, & Health. 2007;25(4):392–403. doi: 10.1037/1091-7527.25.4.392. PMID: 2007-19994-004. Exclusion Code: X1. [CrossRef]

68.

Blair M. Organizations provide $8.7 million to launch a national center to improve care for complex patients. Robert Wood Johnson Foundation. 2016. https://www​.rwjf.org​/en/library/articles-and-news​/2016/03/organizations-provide-8-7-million-to-launch-national-center​.html. Exclusion Code: X7.

69.

Blakey R, Court G, Peaker A, et al. High service users: does the clinical psychologist have a role? Health Bull (Edinb). 2000 May;58(3):203–9. PMID: 11860388. Exclusion Code: X1. [PubMed: 12813826]

70.

Blank FS, Li H, Henneman PL, et al. A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users. J Emerg Nurs. 2005 Apr;31(2):139–44. doi: 10.1016/j.jen.2005.02.008. PMID: 15047073. Exclusion Code: X4. [PubMed: 15834378] [CrossRef]

71.

Bledsoe SE. Adult health care services and psychiatric disorders: the use and costs of health care services in a low income, minority population coming to an urban primary care clinic: ProQuest Information & Learning; 2007. Exclusion Code: X1.

72.

Bleich SN, Sherrod C, Chiang A, et al. Systematic review of programs treating high-need and high-cost people with multiple chronic diseases or disabilities in the United States, 2008–2014. Prev Chronic Dis. 2015 Nov 12;12:E197. doi: 10.5888/pcd12.150275. Exclusion Code: X7. [PMC free article: PMC4651160] [PubMed: 26564013] [CrossRef]

73.

Blumenthal D, Abrams MK. Tailoring complex care management for high-need, high-cost patients. JAMA. 2016 Oct 25;316(16):1657–8. doi: 10.1001/jama.2016.12388. Exclusion Code: X1. [PubMed: 27669168] [CrossRef]

74.

Blumenthal D, Chernof B, Fulmer T, et al. Caring for high-need, high-cost patients - an urgent priority. N Engl J Med. 2016 Sep 8;375(10):909–11. doi: 10.1056/NEJMp1608511. Exclusion Code: X1. [PubMed: 27602661] [CrossRef]

75.

Bobo WV, Hoge CW, Messina MA, et al. Characteristics of repeat users of an inpatient psychiatry service at a large military tertiary care hospital. Mil Med. 2004 Aug;169(8):648–53. doi: 10.7205/milmed.169.8.648. PMID: 15576522. Exclusion Code: X1. [PubMed: 15379078] [CrossRef]

76.

Bodenmann P, Baggio S, Iglesias K, et al. Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study. Int J Equity Health. 2015 Dec 9;14:146. doi: 10.1186/s12939-015-0277-5. PMID: 27142996. Exclusion Code: X1. [PMC free article: PMC4673736] [PubMed: 26645272] [CrossRef]

77.

Bodenmann P, Velonaki VS, Griffin JL, et al. Case management may reduce emergency department frequent use in a universal health coverage system: a randomized controlled trial. J Gen Intern Med. 2017 May;32(5):508–15. doi: 10.1007/s11606-016-3789-9. PMID: 27578689. Exclusion Code: X1. [PMC free article: PMC5400747] [PubMed: 27400922] [CrossRef]

78.

Boehmer KR, Abu Dabrh AM, Gionfriddo MR, et al. Does the chronic care model meet the emerging needs of people living with multimorbidity? A systematic review and thematic synthesis. PLoS One. 2018;13(2):e0190852. doi: 10.1371/journal.pone.0190852. PMID: 29420543. Exclusion Code: X7. [PMC free article: PMC5805171] [PubMed: 29420543] [CrossRef]

79.

Boling PA, Leff B. Comprehensive longitudinal health care in the home for high-cost beneficiaries: a critical strategy for population health management. J Am Geriatr Soc. 2014 Oct;62(10):1974–6. doi: 10.1111/jgs.13049. PMID: 25960393. Exclusion Code: X9. [PubMed: 25294407] [CrossRef]

80.

Bornstein D. The 5 percent: solutions reporting on care for the nation’s sickest. Solutions Journalism Network, Inc.: Commonwealth Fund; 2016. Exclusion Code: X7.

81.

Bradley EH. Identifying effective strategies for coordinating health care and social services for high-need, high-cost patients. Yale University, Yale School of Public Health 2015. https://www​.commonwealthfund​.org/grants/identifying-effective-strategies-coordinating-health-care-and-social-services-high-need-high. Exclusion Code: X7.

82.

Brannon E, Wang T, Lapedis J, et al. Towards a learning health system to reduce emergency department visits at a population level. AMIA Symposium; 2018. Annual Symposium proceedings; 2018. pp. 295–304. Exclusion Code: X1. [PMC free article: PMC6371247] [PubMed: 30815068]

83.

Braveman P, Dekker M, Egerter S, et al. How does housing affect health? An examination of the many ways in which housing can influence health and strategies to improve health through emphasis on healthier homes. 2011. Exclusion Code: X1.

84.

Breland JY, Chee CP, Zulman DM. Racial differences in chronic conditions and sociodemographic characteristics among high-utilizing veterans. J Racial Ethn Health Disparities. 2015 Jun;2(2):167–75. doi: 10.1007/s40615-014-0060-0. PMID: 26147126. Exclusion Code: X4. [PMC free article: PMC6200449] [PubMed: 26863335] [CrossRef]

85.

Brenner JC. Jeffrey C Brenner: on driving down the cost of care. Healthc Financ Manage. 2013 Jan;67(1):72–5. PMID: 23360057. Exclusion Code: X1. [PubMed: 23360057]

86.

Brewster AL, Brault MA, Tan AX, et al. Patterns of collaboration among health care and social services providers in communities with lower health care utilization and costs. Health Serv Res. 2018 Aug;53 Suppl 1:2892–909. doi: 10.1111/1475-6773.12775. Exclusion Code: X1. [PMC free article: PMC6056597] [PubMed: 28925041] [CrossRef]

87.

Brian W. Powers SP, Nupur Mehta. Impact of Complex Care Management on Spending and Utilization for High-Need, High-Cost Medicaid Patients. The American Journal of Managed Care. 2020. Exclusion Code: X12. [PubMed: 32059101]

88.

Bronsky ES, McGraw C, Johnson R, et al. CARES: a community-wide collaboration identifies super-utilizers and reduces their 9-1-1 call, emergency department, and hospital visit rates. Prehosp Emerg Care. 2017 Nov–Dec;21(6):693–9. doi: 10.1080/10903127.2017.1335820. PMID: 25469750. Exclusion Code: X1. [PubMed: 28657819] [CrossRef]

89.

Brooks EM, Winship JM, Kuzel AJ. A “Behind-the-Scenes” Look at Interprofessional Care Coordination: How Person-Centered Care in Safety-Net Health System Complex Care Clinics Produce Better Outcomes. International Journal of Integrated Care. 2020 Apr–Jun;20(2):10. doi: 10.5334/ijic.4734. PMID: WOS:000550985100007. Exclusion Code: X1. [PMC free article: PMC7207252] [PubMed: 32405282] [CrossRef]

90.

Brown AF, Behforouz H, Shah A, et al. The care connections program: A randomized trial of community health workers to improve care for medically and socially complex patients. J Gen Intern Med. 2020;35(SUPPL 1):S288. doi: 10.1007/s11606-020-05890-3. Exclusion Code: X1. [CrossRef]

91.

Brown KE, Fiellin DA, Chawarski MC, et al. A randomized trial of primary intensive care to reduce hospital admissions in high utilizers. J Gen Intern Med. 2002 Apr;17:121-. PMID: WOS:000175158200432. Exclusion Code: X1.

92.

Brown KE, Levine JM, Fiellin DA, et al. Primary intensive care: pilot study of a primary care-based intervention for high-utilizing patients. Dis Manag. 2005 Jun;8(3):169–77. doi: 10.1089/dis.2005.8.169. PMID: 16359548. Exclusion Code: X1. [PubMed: 15966782] [CrossRef]

93.

Broyles J. Strategies to promulgate advanced illness care models that work. Coalition to Transform Advanced Care. Washington, DC: 2013. Exclusion Code: X1.

94.

Bryk J, Fischer GS, Lyons A, et al. Improvement in quality metrics by the UPMC enhanced care program: a novel super-utilizer program. Popul Health Manag. 2018 Jun;21(3):217–21. doi: 10.1089/pop.2017.0064. PMID: 27612609. Exclusion Code: X1. [PubMed: 28945512] [CrossRef]

95.

Buchanan D, Doblin B, Sai T, et al. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006 Jul;96(7):1278–81. doi: 10.2105/ajph.2005.067850. PMID: 16735635. Exclusion Code: X1. [PMC free article: PMC1483848] [PubMed: 16735635] [CrossRef]

96.

Buck JA, Teich JL, Miller K. Use of mental health and substance abuse services among high-cost Medicaid enrollees. Adm Policy Ment Health. 2003 Sep;31(1):3–14. doi: 10.1023/a:1026089422101. PMID: 26850904. Exclusion Code: X9. [PubMed: 14650645] [CrossRef]

97.

Buja A, Claus M, Perin L, et al. Multimorbidity patterns in high-need, high-cost elderly patients. PLoS One. 2018;13(12):e0208875. doi: 10.1371/journal.pone.0208875. PMID: 29560049. Exclusion Code: X1. [PMC free article: PMC6296662] [PubMed: 30557384] [CrossRef]

98.

Buja A, Rivera M, De Battisti E, et al. Multimorbidity and Hospital Admissions in High-Need, High-Cost Elderly Patients. J Aging Health. 2020 Jun/Jul;32(5–6):259–68. doi: 10.1177/0898264318817091. PMID: 31682499. Exclusion Code: X6. [PubMed: 30522388] [CrossRef]

99.

Burns C, Wang NE, Goldstein BA, et al. Characterization of young adult emergency department users: evidence to guide policy. J Adolesc Health. 2016 Dec;59(6):654–61. doi: 10.1016/j.jadohealth.2016.07.011. PMID: 27605647. Exclusion Code: X4. [PubMed: 27613220] [CrossRef]

100.

Burns J. Treating Super Utilizers in Rural Pennsylvania. Robert Wood Johnson Foundation. Princeton, NJ: 2013. https://www​.rwjf.org​/en/library/articles-and-news​/2013/09/treating-superusers-in-rural-pennsylvania​.html. Exclusion Code: X1.

101.

Burns J. Cleveland Medical Center aims to improve care for super utilizers. Robert Wood Johnson Foundation. Princeton, NJ: 2013. https://www​.rwjf.org​/en/library/articles-and-news​/2013/09/cleveland-improves-care-for-super-utilizers.html. Exclusion Code: X1.

102.

Bush H. Caring for the costliest. (Cover story). H&HN: Hospitals & Health Networks. 2012;86(11):24–9. PMID: 83779325. Exclusion Code: X1. [PubMed: 23214040]

103.

Bush H. Tackling the high cost of chronic disease. Hosp Health Netw. 2012 Oct;86(10):34–6, 8, 40. PMID: 26454353. Exclusion Code: X1. [PubMed: 23163172]

104.

Bynum JPW. Measuring what matters most to people with complex needs. Health Aff (Millwood). Bethesda, MD: Health Affairs; 2018. Exclusion Code: X1.

105.

Bynum JPW, Austin A, Carmichael D, et al. High-Cost Dual Eligibles’ Service Use Demonstrates The Need For Supportive And Palliative Models Of Care. Health Aff (Millwood). 2017 Jul 1;36(7):1309–17. doi: 10.1377/hlthaff.2017.0157. PMID: 31029256. Exclusion Code: X1. [PMC free article: PMC5633373] [PubMed: 28679819] [CrossRef]

106.

California Health Care Foundation. Data symposium and webinar on high utilizers of Medi-Cal Services. Oakland, CA: California Health Care Foundation; 2015. https://www​.chcf.org​/event/data-symposium-and-webinar-on-high-utilizers-of-medi-cal-services/2019. Exclusion Code: X1.

107.

California Health Care Foundation. Integrated clinics for high utilizers conference. Oakland, CA: California Health Care Foundation; 2015. https://www​.chcf.org​/event/integrated-clinics-for-high-utilizers-conference/2019. Exclusion Code: X1.

108.

California Health Care Foundation. Care integration for patients with complex needs. California Health Care Foundation. Oakland, CA: 2017. https://www​.chcf.org​/project/care-integration-for-patients-with-complex-needs/. Exclusion Code: X1.

109.

California Health Care Foundation. CIN Webinar Series — The ROI for addressing social needs in health care (#2). Oakland, CA: California Health Care Foundation; 2018. https://www​.chcf.org​/event/cin-webinar-series-roi-addressing-social-needs-health-care-2/2019. Exclusion Code: X1.

110.

Capp R, Rosenthal MS, Desai MM, et al. Characteristics of Medicaid enrollees with frequent ED use. Am J Emerg Med. 2013 Sep;31(9):1333–7. doi: 10.1016/j.ajem.2013.05.050. PMID: 23850143. Exclusion Code: X4. [PubMed: 23850143] [CrossRef]

111.

Capp R, Zane R. Using emergency department community health workers as a bridge to ongoing care for frequent ED users. Value and Quality Innovations in Acute and Emergency Care. 2017:209–14. Exclusion Code: X1.

112.

Carney KJL. PRACTITIONER APPLICATION: An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System. J Healthc Manag. 2020 Jan–Feb;65(1):71–2. doi: 10.1097/jhm-d-19-00237. PMID: WOS:000561759100012. Exclusion Code: X8. [PubMed: 31913242] [CrossRef]

113.

Carpiac-Claver M, Guzman JS, Castle SC. The Comprehensive Care Clinic. Health Soc Work. 2007 Aug;32(3):219–23. doi: 10.1093/hsw/32.3.219. PMID: 17896679. Exclusion Code: X1. [PubMed: 17896679] [CrossRef]

114.

Carroll CP, Carlton Jr H, Fagan P, et al. The course and correlates of high hospital utilization in sickle cell disease: evidence from a large, urban Medicaid managed care organization. Am J Hematol. 2009;84(10):666–70. doi: 10.1002/ajh.21515. Exclusion Code: X1. [PMC free article: PMC2783233] [PubMed: 19743465] [CrossRef]

115.

Castillo EM, Brennan JJ, Killeen JP, et al. Identifying frequent users of emergency department resources. J Emerg Med. 2014 Sep;47(3):343–7. doi: 10.1016/j.jemermed.2014.03.014. PMID: 27604932. Exclusion Code: X4. [PubMed: 24813059] [CrossRef]

116.

Center for Health Care Strategies. Medicaid-financed services in supportive housing for high-need homeless beneficiaries. 2012. Exclusion Code: X1.

117.

. The Super-Utilizer Summit: resources to support emerging programs. Super-Utilizer Summit; 2013; Alexandra, Virginia. 2442: Center for Health Care Strategies. Exclusion Code: X1.

118.

Center for Integrative Medicine. Webinar — new online resources for complex care. Oakland, CA: California Health Care Foundation; 2015. https://www​.chcf.org​/event/webinar-new-online-resources-for-complex-care/2019. Exclusion Code: X1.

119.

Chambers C, Chiu S, Katic M, et al. High utilizers of emergency health services in a population-based cohort of homeless adults. Am J Public Health. 2013;103(S2):S302–10. doi: 10.2105/AJPH.2013.301397. PMID: 104161876. Language: English. Entry Date: 20131126. Revision Date: 20150711. Publication Type: Journal Article. Exclusion Code: X1. [PMC free article: PMC3969147] [PubMed: 24148033] [CrossRef]

120.

Chan B, Edwards ST, Devoe M, et al. The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale. Addict Sci Clin Pract. 2018;13(1):27. doi: 10.1186/s13722-018-0128-y. PMID: CN-01925167. Exclusion Code: X1. [PMC free article: PMC6295087] [PubMed: 30547847] [CrossRef]

121.

Chan B, Edwards ST, Mitchell M, et al. Can an intensive ambulatory care intervention improve the experience of high-utilizing patients?: 6-month outcomes of the summit randomized controlled trial. J Gen Intern Med. 2019;34(2):S151–. doi: 10.1007/11606.1525-1497. PMID: CN-01976812. Exclusion Code: X1. [CrossRef]

122.

Chan B, Mitchell M, Edwards ST, et al. Implementation and evaluation of summit, an ambulatory intensive care (A-ICU) model of primary care for high-utilizersata healthcare for the homeless site. J Gen Intern Med. 2018;33(2):791–2. PMID: CN-01606174. Exclusion Code: X1.

123.

Chan BT, Ovens HJ. Frequent users of emergency departments. Do they also use family physicians’ services? Can Fam Physician. 2002 Oct;48:1654–60. PMID: 12870409. Exclusion Code: X1. [PMC free article: PMC2213944] [PubMed: 12449550]

124.

Chandler D, Spicer G. Capitated assertive community treatment program savings: system implications. Adm Policy Ment Health. 2002;30(1):3–19. PMID: CN-00412904. Exclusion Code: X1. [PubMed: 12546253]

125.

Chang E. Intensive Primary Care via Patient Aligned Care Teams (PACT) Intensive Management @ VA. 2019. Exclusion Code: X1.

126.

Chang ET, Raja PV, Stockdale SE, et al. What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study. Healthc (Amst). 2018 Dec;6(4):231–7. doi: 10.1016/j.hjdsi.2017.10.001. PMID: 29102480. Exclusion Code: X1. [PubMed: 29102480] [CrossRef]

127.

Chang ET, Zulman DM, Asch SM, et al. An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation. Contemp Clin Trials. 2018 Jun;69:65–75. doi: 10.1016/j.cct.2018.04.008. PMID: 29698772. Exclusion Code: X1. [PubMed: 29698772] [CrossRef]

128.

Chang HY, Boyd CM, Leff B, et al. Identifying Consistent High-cost Users in a Health Plan: Comparison of Alternative Prediction Models. Med Care. 2016 Sep;54(9):852–9. doi: 10.1097/mlr.0000000000000566. PMID: 27521041. Exclusion Code: X9. [PubMed: 27326548] [CrossRef]

129.

Chapman H, Farndon L, Matthews R, et al. Okay to Stay? A new plan to help people with long-term conditions remain in their own homes. Primary Health Care Research & Development (Cambridge University Press / UK). 2019;20:N.PAG-N.PAG. doi: 10.1017/S1463423618000786. PMID: 134961288. Language: English. Entry Date: 20190302. Revision Date: 20190304. Publication Type: Article. Exclusion Code: X6. [PMC free article: PMC6476400] [PubMed: 30428937] [CrossRef]

130.

Chaput YJ, Lebel MJ. An examination of the temporal and geographical patterns of psychiatric emergency service use by multiple visit patients as a means for their early detection. BMC Psychiatry. 2007 Oct 29;7:60. doi: 10.1186/1471-244x-7-60. PMID: 17493977. Exclusion Code: X1. [PMC free article: PMC2190759] [PubMed: 17963530] [CrossRef]

131.

Chaput YJ, Lebel MJ. Demographic and clinical profiles of patients who make multiple visits to psychiatric emergency services. Psychiatr Serv. 2007 Mar;58(3):335–41. doi: 10.1176/ps.2007.58.3.335. PMID: 16859808. Exclusion Code: X1. [PubMed: 17325106] [CrossRef]

132.

Chen BK, Cheng X, Bennett K, et al. Travel distances, socioeconomic characteristics, and health disparities in nonurgent and frequent use of hospital emergency departments in South Carolina: a population-based observational study. BMC Health Serv Res. 2015 May 16;15:203. doi: 10.1186/s12913-015-0864-6. PMID: 25970845. Exclusion Code: X4. [PMC free article: PMC4448557] [PubMed: 25982735] [CrossRef]

133.

Cherner R, Ecker J, Louw A, et al. Lessons learned from piloting a pain assessment program for high frequency emergency department users. Scand J Pain. 2019 Jul 26;19(3):545–52. doi: 10.1515/sjpain-2018-0128. PMID: 30834969. Exclusion Code: X6. [PubMed: 31031261] [CrossRef]

134.

Chernof B, McClellan M. Form follows funding: opportunities for advancing outcomes for complex care patients using alternative payment methods. Health Affairs Blog. Bethesda, MD: Health Affairs; 2018. Exclusion Code: X1.

135.

Chhabra M, Spector E, Demuynck S, et al. Assessing the relationship between housing and health among medically complex, chronically homeless individuals experiencing frequent hospital use in the United States. Health Soc Care Community. 2020 Jan;28(1):91–9. doi: 10.1111/hsc.12843. PMID: 30629016. Exclusion Code: X1. [PubMed: 31476092] [CrossRef]

136.

Chiu Y, Racine-Hemmings F, Dufour I, et al. Statistical tools used for analyses of frequent users of emergency department: a scoping review. Bmj Open. 2019 May;9(5). doi: 10.1136/bmjopen-2018-027750. PMID: WOS:000471192800303. Exclusion Code: X1. [PMC free article: PMC6537981] [PubMed: 31129592] [CrossRef]

137.

Chiu YM, Vanasse A, Courteau J, et al. Persistent frequent emergency department users with chronic conditions: A population-based cohort study. PLoS One. 2020;15(2):e0229022. doi: 10.1371/journal.pone.0229022. PMID: 30780151. Exclusion Code: X6. [PMC free article: PMC7015381] [PubMed: 32050010] [CrossRef]

138.

Chuang E, Pourat N, Haley LA, et al. Integrating Health And Human Services In California’s Whole Person Care Medicaid 1115 Waiver Demonstration. Health Aff (Millwood). 2020 Apr;39(4):639–48. doi: 10.1377/hlthaff.2019.01617. PMID: WOS:000523599600015. Exclusion Code: X1. [PubMed: 32250689] [CrossRef]

139.

Chukmaitov AS, Tang A, Carretta HJ, et al. Characteristics of all, occasional, and frequent emergency department visits due to ambulatory care-sensitive conditions in Florida. J Ambul Care Manage. 2012 Apr–Jun;35(2):149–58. doi: 10.1097/JAC.0b013e318244d222. PMID: 23091842. Exclusion Code: X3. [PubMed: 22415289] [CrossRef]

140.

Claxton G, Rae M, Levitt L. A look at people who have persistently high spending on health care. Kaiser Family Foundation. 2019. https://www​.kff.org/health-costs​/issue-brief​/a-look-at-people-who-have-persistently-high-spending-on-health-care/. Exclusion Code: X7.

141.

ClinicalTrials​.gov. Contra Costa Health Services Whole Person Care (CommunityConnect) Program Evaluation. https:​//clinicaltrials​.gov/show/NCT04000074. 2019. PMID: CN-01952848. Exclusion Code: X9.

142.

ClinicalTrials​.gov. High Risk Outpatient Intern-led Care (HeROIC) Clinic Initiative. https:​//clinicaltrials​.gov/show/NCT04375189. 2020. PMID: CN-02103718. Exclusion Code: X11.

143.

CMS. Integrated care resource center available to all states. Resources available to all states to coordinate care for high-cost, high-need beneficiaries. Baltimore, MD: U.S. Centers for Medicare & Medicaid Services; 2017. Exclusion Code: X1.

144.

Cohen D, Wodchis WP, Calzavara A. Can high-cost spending in the community signal admission to hospital? A dynamic modeling study for urgent and elective cardiovascular patients. BMC Health Serv Res. 2018 Nov 15;18(1):861. doi: 10.1186/s12913-018-3639-z. PMID: 23297608. Exclusion Code: X1. [PMC free article: PMC6238318] [PubMed: 30442140] [CrossRef]

145.

Coles S. Strategies to Improve Corporate Financial Investment in Care Coordination Programs. Walden University, ProQuest Dissertations Publishing; 2018. Exclusion Code: X1.

146.

Colla C. Evaluating the formation and performance of accountable care organizations: focus on high-need, high-cost populations. Dartmouth College, Dartmouth Institute for Health Policy and Clinical Practice. 2014. Exclusion Code: X7.

147.

Colla C, Yang WD, Mainor AJ, et al. Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries. Health Serv Res. 2020 Dec;55:1085–97. doi: 10.1111/1475-6773.13580. PMID: WOS:000583295700001. Exclusion Code: X1. [PMC free article: PMC7720705] [PubMed: 33104254] [CrossRef]

148.

Collins L, Sicks S, Hass RW, et al. Self-efficacy and empathy development through interprofessional student hotspotting. Journal of Interprofessional Care.4. doi: 10.1080/13561820.2020.1712337. PMID: WOS:000523149400001. Exclusion Code: X1. [PubMed: 32233896] [CrossRef]

149.

Connors JDN, Binkley BL, Graff JC, et al. How patient experience informed the SafeMed Program: Lessons learned during a Health Care Innovation Award to improve care for super-utilizers. Healthcare-the Journal of Delivery Science and Innovation. 2019 Mar;7(1):13–21. doi: 10.1016/j.hjdsi.2018.02.002. PMID: WOS:000461053700004. Exclusion Code: X1. [PubMed: 29477610] [CrossRef]

150.

Considine JT. A Feasibility Study for an Advanced Practice Registered Nurse Led Community Engagement Program. Shepherd University, ProQuest Dissertations Publishing; 2018. Exclusion Code: X4.

151.

Cook LJ, Knight S, Junkins EP, Jr., et al. Repeat patients to the emergency department in a statewide database. Acad Emerg Med. 2004 Mar;11(3):256–63. PMID: 11827601. Exclusion Code: X4. [PubMed: 15001405]

152.

Cornell PY, Halladay CW, Ader J, et al. Embedding Social Workers In Veterans Health Administration Primary Care Teams Reduces Emergency Department Visits. Health Aff (Millwood). 2020 Apr;39(4):603–12. doi: 10.1377/hlthaff.2019.01589. PMID: WOS:000523599600011. Exclusion Code: X1. [PubMed: 32250673] [CrossRef]

153.

Costi S, Pellegrini M, Cavuto S, et al. Occupational therapy in rehabilitation of complex patients: protocol for a superiority randomized controlled trial. Journal of interprofessional care. 2020:1–8. doi: 10.1080/13561820.2020.1711720. PMID: CN-02086974. Exclusion Code: X11. [PubMed: 32013621] [CrossRef]

154.

Coughlin TA, Long SK. Health care spending and service use among high-cost Medicaid beneficiaries, 2002–2004. Inquiry. 2009 Winter;46(4):405–17. doi: 10.5034/inquiryjrnl_46.4.405. PMID: 28723691. Exclusion Code: X9. [PubMed: 20184167] [CrossRef]

155.

Couture EM, Chouinard MC, Fortin M, et al. The relationship between health literacy and quality of life among frequent users of health care services: a cross-sectional study. Health Qual Life Outcomes. 2017 Jul 6;15(1):137. doi: 10.1186/s12955-017-0716-7. PMID: 27862572. Exclusion Code: X1. [PMC free article: PMC5500997] [PubMed: 28683743] [CrossRef]

156.

Couture EM, Chouinard MC, Fortin M, et al. The relationship between health literacy and patient activation among frequent users of healthcare services: a cross-sectional study. BMC Fam Pract. 2018 Mar 9;19(1):38. doi: 10.1186/s12875-018-0724-7. PMID: 30118627. Exclusion Code: X1. [PMC free article: PMC5845227] [PubMed: 29523095] [CrossRef]

157.

Cox WK, Penny LC, Statham RP, et al. Admission intervention team: medical center based intensive case management of the seriously mentally ill. Care Manag J. 2003 Winter;4(4):178–84. PMID: 15763120. Exclusion Code: X1. [PubMed: 15628650]

158.

Craig C, Stiefel M, Carr E, et al. WIHI: when everyone knows your name: identifying patients with complex needs. Institute for Healthcare Improvement; 2015. Exclusion Code: X7.

159.

Craig C ED, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI. 2011. Exclusion Code: X11.

160.

Crane D, Christenson J. The medical offset effect: patterns in outpatient services reduction for high utilizers of health care. Contemporary Family Therapy: An International Journal. 2008;30(2):127–38. doi: 10.1007/s10591-008-9058-2. PMID: 31368504. Exclusion Code: X1. [CrossRef]

161.

Crane M, Warnes AM. Primary health care services for single homeless people: defects and opportunities. Fam Pract. 2001 Jun;18(3):272–6. doi: 10.1093/fampra/18.3.272. PMID: 12195545. Exclusion Code: X1. [PubMed: 11356733] [CrossRef]

162.

Cruwys T, Wakefield JRH, Sani F, et al. Social isolation predicts frequent attendance in primary care. Ann Behav Med. 2018 Oct;52(10):817–29. doi: 10.1093/abm/kax054. PMID: WOS:000449052300001. Exclusion Code: X1. [PubMed: 30212847] [CrossRef]

163.

Cullen W, O’Brien S, O’Carroll A, et al. Chronic illness and multimorbidity among problem drug users: a comparative cross sectional pilot study in primary care. BMC Fam Pract. 2009 Apr 21;10:25. doi: 10.1186/1471-2296-10-25. PMID: 17466465. Exclusion Code: X1. [PMC free article: PMC2678984] [PubMed: 19383141] [CrossRef]

164.

Cunningham PJ. Predicting high-cost privately insured patients based on self-reported health and utilization data. Am J Manag Care. 2017 Jul 1;23(7):e215–e22. PMID: 27914968. Exclusion Code: X9. [PubMed: 28850789]

165.

Curtin CM, Suarez PA, Di Ponio LA, et al. Who are the women and men in Veterans Health Administration’s current spinal cord injury population? J Rehabil Res Dev. 2012;49(3):351–60. PMID: 22606057. Exclusion Code: X1. [PubMed: 22773195]

166.

Dang S, Ruiz DI, Klepac L, et al. Key Characteristics for Successful Adoption and Implementation of Home Telehealth Technology in Veterans Affairs Home-Based Primary Care: An Exploratory Study. Telemed J E Health. 2019 Apr;25(4):309–18. doi: 10.1089/tmj.2018.0009. PMID: 30887432. Exclusion Code: X11. [PubMed: 29969381] [CrossRef]

167.

Darke S, Havard A, Ross J, et al. Changes in the use of medical services and prescription drugs among heroin users over two years. Drug Alcohol Rev. 2007 Mar;26(2):153–9. doi: 10.1080/09595230601146660. PMID: 17325106. Exclusion Code: X1. [PubMed: 17364850] [CrossRef]

168.

Das LT, Abramson EL, Kaushal R. High-need, high-cost patients offer solutions for improving their care and reducing costs. NEJM Catal. 2019;2019. Exclusion Code: X7.

169.

Das LT, Kaushal R, Garrison K, et al. Drivers of preventable high health care utilization: a qualitative study of patient, physician and health system leader perspectives. J Health Serv Res Policy. 2020;25(4):220–8. doi: 10.1177/1355819619873685. PMID: 145701247. Language: English. Entry Date: 20200922. Revision Date: 20200922. Publication Type: Article. Exclusion Code: X12. [PubMed: 31505976] [CrossRef]

170.

Davis A, Osuji T, Chen A, et al. Data-driven decision making for interventions with complex needs’ patients: Identifying the right target population. Health Serv Res. 2020;55(SUPPL 1):75. doi: 10.1111/1475-6773.13433. Exclusion Code: X7. [CrossRef]

171.

Davis AC, Osuji TA, Chen J, et al. Identifying Populations with Complex Needs: Variation in Approaches Used to Select Complex Patient Populations. Popul Health Manag. 2020. doi: 10.1089/pop.2020.0153. Exclusion Code: X7. [PubMed: 32941105] [CrossRef]

172.

Davis JW, Chung R, Juarez DT. Prevalence of comorbid conditions with aging among patients with diabetes and cardiovascular disease. Hawaii Med J. 2011 Oct;70(10):209–13. PMID: 20106475. Exclusion Code: X1. [PMC free article: PMC3215980] [PubMed: 22162595]

173.

Davis R, Nuamah A. Identifying “Rising Risk” Populations: Early Lessons from the Complex Care Innovation Lab. Center for Health Care Strategies; 2020. Exclusion Code: X2.

174.

Davis R, Somers SA. A collective national approach to fostering innovation in complex care. Healthc (Amst). 2018 Mar;6(1):1–3. doi: 10.1016/j.hjdsi.2017.05.003. PMID: 28673816. Exclusion Code: X7. [PubMed: 28673816] [CrossRef]

175.

de Miguel-Diez J, Lopez-de-Andres A, Herandez-Barrera V, et al. Effect of the economic crisis on the use of health and home care services among Spanish COPD patients. Int J Chron Obstruct Pulmon Dis. 2018;13:725–39. doi: 10.2147/copd.S150308. PMID: 28374978. Exclusion Code: X1. [PMC free article: PMC5836665] [PubMed: 29535513] [CrossRef]

176.

Deacon B, Lickel J, Abramowitz JS. Medical utilization across the anxiety disorders. J Anxiety Disord. 2008;22(2):344–50. doi: 10.1016/j.janxdis.2007.03.004. PMID: 19197621. Exclusion Code: X1. [PubMed: 17420113] [CrossRef]

177.

Delaney RK, Sisco-Taylor B, Fagerlin A, et al. A systematic review of intensive outpatient care programs for high-need, high-cost patients. Transl Behav Med. 2020;10(5):1187–99. doi: 10.1093/tbm/ibaa017. Exclusion Code: X7. [PubMed: 33044534] [CrossRef]

178.

Delcher C, Yang C, Ranka S, et al. Variation in outpatient emergency department utilization in Texas Medicaid: a state-level framework for finding “superutilizers”. Int J Emerg Med. 2017 Dec 4;10(1):31. doi: 10.1186/s12245-017-0157-4. PMID: 29204728. Exclusion Code: X9. [PMC free article: PMC5714939] [PubMed: 29204728] [CrossRef]

179.

Dent A, Hunter G, Webster AP. The impact of frequent attenders on a UK emergency department. Eur J Emerg Med. 2010 Dec;17(6):332–6. doi: 10.1097/MEJ.0b013e328335623d. PMID: 20136800. Exclusion Code: X1. [PubMed: 20038842] [CrossRef]

180.

Dent AW, Phillips GA, Chenhall AJ, et al. The heaviest repeat users of an inner city emergency department are not general practice patients. Emerg Med (Fremantle). 2003 Aug;15(4):322–9. PMID: 11502954. Exclusion Code: X1. [PubMed: 14631698]

181.

Dew MA, Goycoolea JM, Harris RC, et al. An internet-based intervention to improve psychosocial outcomes in heart transplant recipients and family caregivers: development and evaluation. J Heart Lung Transplant. 2004 Jun;23(6):745–58. PMID: 15182240. Exclusion Code: X1. [PubMed: 15366436]

182.

Di Lorenzo R, Sagona M, Landi G, et al. The revolving door phenomenon in an Italian acute psychiatric ward: a 5-year retrospective analysis of the potential risk factors. J Nerv Ment Dis. 2016;204(9):686–92. doi: 10.1097/NMD.0000000000000540. PMID: 118071724. Language: English. Entry Date: 20180723. Revision Date: 20171231. Publication Type: journal article. Journal Subset: Biomedical. Exclusion Code: X1. [PubMed: 27227558] [CrossRef]

183.

Di Mauro R, Di Silvio V, Bosco P, et al. Case management programs in emergency department to reduce frequent user visits: a systematic review. Acta Biomed. 2019 Jul 8;90(6-s):34–40. doi: 10.23750/abm.v90i6-S.8390. PMID: 31059373. Exclusion Code: X7. [PMC free article: PMC6776176] [PubMed: 31292413] [CrossRef]

184.

Diaz T. In Memoriam. Patient Educ Couns. 2020 Jun;103(6):1258–9. doi: 10.1016/j.pec.2019.11.027. PMID: WOS:000553018800024. Exclusion Code: X8. [CrossRef]

185.

DiPietro BY. Medicaid accountable care organizations: a case study with Hennepin Health. 2018 May 2018. Exclusion Code: X1.

186.

DiPietro BY, Kindermann D, Schenkel SM. Ill, itinerant, and insured: the top 20 users of emergency departments in Baltimore city. ScientificWorldJournal. 2012;2012:726568. doi: 10.1100/2012/726568. PMID: 22162595. Exclusion Code: X4. [PMC free article: PMC3345528] [PubMed: 22606057] [CrossRef]

187.

Doheny M, Agerholm J, Orsini N, et al. Socio-demographic differences in the frequent use of emergency department care by older persons: a population-based study in Stockholm County. BMC Health Serv Res. 2019 Mar 29;19(1):202. doi: 10.1186/s12913-019-4029-x. PMID: 29620961. Exclusion Code: X1. [PMC free article: PMC6440084] [PubMed: 30922354] [CrossRef]

188.

Dollard J, Harvey G, Dent E, et al. Older people who are frequent users of acute care: a symptom of fragmented care? A case series report on patients’ pathways of care. J Frailty Aging. 2018;7(3):193–5. doi: 10.14283/10.14283/jfa.2018.12. PMID: 29305202. Exclusion Code: X1. [PubMed: 30095151] [CrossRef]

189.

Dombrowski JC, Ramchandani M, Dhanireddy S, et al. The Max Clinic: medical care designed to engage the hardest-to-reach persons living with HIV in Seattle and King County, Washington. AIDS Patient Care STDS. 2018 Apr;32(4):149–56. doi: 10.1089/apc.2017.0313. PMID: 30670044. Exclusion Code: X1. [PMC free article: PMC5905858] [PubMed: 29630852] [CrossRef]

190.

Domenech-Briz V, Romero RG, de Miguel-Montoya I, et al. Results of Nurse Case Management in Primary Heath Care: Bibliographic Review. Int J Environ Res Public Health. 2020 Dec;17(24):17. doi: 10.3390/ijerph17249541. PMID: WOS:000602841900001. Exclusion Code: X7. [PMC free article: PMC7766905] [PubMed: 33419267] [CrossRef]

191.

Donate-Martinez A, Rodenas F, Garces J. Impact of a primary-based telemonitoring programme in HRQOL, satisfaction and usefulness in a sample of older adults with chronic diseases in Valencia (Spain). Arch Gerontol Geriatr. 2016 Jan–Feb;62:169–75. doi: 10.1016/j.archger.2015.09.008. PMID: 27432036. Exclusion Code: X1. [PubMed: 26446784] [CrossRef]

192.

Doran KM, Vashi AA, Platis S, et al. Navigating the boundaries of emergency department care: addressing the medical and social needs of patients who are homeless. Am J Public Health. 2013 Dec;103 Suppl 2:S355–60. doi: 10.2105/ajph.2013.301540. PMID: 24148054. Exclusion Code: X1. [PMC free article: PMC3969133] [PubMed: 24148054] [CrossRef]

193.

Doupe MB, Palatnick W, Day S, et al. Frequent users of emergency departments: developing standard definitions and defining prominent risk factors. Ann Emerg Med. 2012 Jul;60(1):24–32. doi: 10.1016/j.annemergmed.2011.11.036. PMID: 22221292. Exclusion Code: X1. [PubMed: 22305330] [CrossRef]

194.

Dowd BE, Swenson T, Parashuram S, et al. PQRS participation, inappropriate utilization of health care services, and Medicare expenditures. Med Care Res Rev. 2016 Feb;73(1):106–23. doi: 10.1177/1077558715597846. PMID: 27166469. Exclusion Code: X1. [PubMed: 26324510] [CrossRef]

195.

Downey LV, Zun LS. Reasons for readmissions: what are the reasons for 90-day readmissions of psychiatric patients from the ED? Am J Emerg Med. 2015 Oct;33(10):1489–91. doi: 10.1016/j.ajem.2015.06.056. PMID: 26206441. Exclusion Code: X1. [PubMed: 26164411] [CrossRef]

196.

Dreyfus KS. Adult attachment theory and diabetes mellitus: an examination of healthcare utilization and biopsychosocial health: ProQuest Information & Learning; 2015. Exclusion Code: X1.

197.

Dryden EM, King K, Touw S. Facilitators and Barriers to Successful Engagement in a Complex Care Management Program: Patient and Care Manager Perspectives. J Health Care Poor Underserved. 2019 May;30(2):789–805. doi: 10.1353/hpu.2019.0056. PMID: WOS:000468495900026. Exclusion Code: X1. [PubMed: 31130551] [CrossRef]

198.

Duenas M, Sow S, Poveda C, et al. Engaging the disengaged: outcomes of recruitment and enrollment of high-risk, high-utilizers into an intensive outpatient primary care program for complex care management. J Gen Intern Med. 2018;33(2):783–4. Exclusion Code: X1.

199.

DuGoff EH, Boyd C, Anderson G. Complex Patients and Quality of Care in Medicare Advantage. J Am Geriatr Soc. 2020 Feb;68(2):395–402. doi: 10.1111/jgs.16236. PMID: 31054588. Exclusion Code: X1. [PubMed: 31675101] [CrossRef]

200.

DuGoff EH, Buckingham W, Kind AJ, et al. Targeting high-need beneficiaries in Medicare Advantage: opportunities to address medical and social needs. Issue Brief (Commonw Fund). 2019 Feb 1;2019:1–14. PMID: 29554592. Exclusion Code: X1. [PubMed: 30938944]

201.

Durand-Zaleski I. U.S.–France International Meeting on care for high-need, high-cost patients. Assistance Publique-Hôpitaux de Paris: Commonwealth Fund; 2015. Exclusion Code: X7.

202.

Duru OK, Harwood J, Moin T, et al. Evaluation of a National Care Coordination Program to Reduce Utilization Among High-cost, High-need Medicaid Beneficiaries With Diabetes. Med Care. 2020 Jun;58 Suppl 6 Suppl 1:S14–s21. doi: 10.1097/mlr.0000000000001315. PMID: 32818784. Exclusion Code: X1. [PMC free article: PMC10653047] [PubMed: 32412949] [CrossRef]

203.

Eden E, DeKosky A, Chen LW, et al. High utilizers of condition help: demographic and medical characteristics of patients who repeatedly activate rapid response teams. J Gen Intern Med. 2017;32(2):S205–S6. Exclusion Code: X1.

204.

Edwards ST, Saha S, Prentice JC, et al. Preventing hospitalization with Veterans Affairs home-based primary care: which individuals benefit most? J Am Geriatr Soc. 2017 Aug;65(8):1676–83. doi: 10.1111/jgs.14843. PMID: 28410824. Exclusion Code: X1. [PMC free article: PMC8284941] [PubMed: 28323324] [CrossRef]

205.

Englander H, Michaels L, Chan B, et al. The care transitions innovation (C-train) for socioeconomically disadvantaged adults, results of a clustered randomized controlled trial. J Gen Intern Med. 2014;29:S221–. PMID: CN-01010119. Exclusion Code: X1. [PMC free article: PMC4238212] [PubMed: 24913003]

206.

Epstein DH, Preston KL. Does cannabis use predict poor outcome for heroin-dependent patients on maintenance treatment? Past findings and more evidence against. Addiction. 2003 Mar;98(3):269–79. PMID: 12945810. Exclusion Code: X1. [PMC free article: PMC2943839] [PubMed: 12603227]

207.

Etemad LR, McCollam PL. Predictors of high-cost managed care patients with acute coronary syndrome. Curr Med Res Opin. 2005 Dec;21(12):1977–84. doi: 10.1185/030079905x74970. PMID: 30355286. Exclusion Code: X4. [PubMed: 16368049] [CrossRef]

208.

Eton DT, Lee MK, St Sauver JL, et al. Known-groups validity and responsiveness to change of the Patient Experience with Treatment and Self-management (PETS vs. 2.0): a patient-reported measure of treatment burden. Qual Life Res. 2020 Nov;29(11):3143–54. doi: 10.1007/s11136-020-02546-x. PMID: WOS:000539517700001. Exclusion Code: X1. [PMC free article: PMC8012109] [PubMed: 32524346] [CrossRef]

209.

Ettner SL, Frank RG, McGuire TG, et al. Risk adjustment alternatives in paying for behavioral health care under Medicaid. Health Serv Res. 2001 Aug;36(4):793–811. PMID: 14727682. Exclusion Code: X1. [PMC free article: PMC1089257] [PubMed: 11508640]

210.

Faresjo A, Grodzinsky E, Foldevi M, et al. Patients with irritable bowel syndrome in primary care appear not to be heavy healthcare utilizers. Aliment Pharmacol Ther. 2006 Mar 15;23(6):807–14. doi: 10.1111/j.1365-2036.2006.02815.x. PMID: 16672680. Exclusion Code: X1. [PubMed: 16556183] [CrossRef]

211.

Feinglass J, Norman G, Golden RL, et al. Integrating Social Services and Home-Based Primary Care for High-Risk Patients. Popul Health Manag. 2018 Apr;21(2):96–101. doi: 10.1089/pop.2017.0026. PMID: 28609187. Exclusion Code: X9. [PubMed: 28609187] [CrossRef]

212.

Ferrari S, Galeazzi GM, Mackinnon A, et al. Frequent attenders in primary care: impact of medical, psychiatric and psychosomatic diagnoses. Psychother Psychosom. 2008;77(5):306–14. doi: 10.1159/000142523. PMID: 16460995. Exclusion Code: X1. [PubMed: 18600036] [CrossRef]

213.

Fertel BS, Hart KW, Lindsell CJ, et al. Patients who use multiple EDs: quantifying the degree of overlap between ED populations. West J Emerg Med. 2015 Mar;16(2):229–33. doi: 10.5811/westjem.2015.1.22838. PMID: 26447915. Exclusion Code: X4. [PMC free article: PMC4380370] [PubMed: 25834661] [CrossRef]

214.

Fertel BS, Podolsky SR, Mark J, et al. Impact of an individual plan of care for frequent and high utilizers in a large healthcare system. Am J Emerg Med. 2019. doi: 10.1016/j.ajem.2019.02.032. Exclusion Code: X1. [PubMed: 30824276] [CrossRef]

215.

Figueroa JF, Joynt Maddox KE, Beaulieu N, et al. Concentration of potentially preventable spending among high-cost Medicare subpopulations: an observational study. Ann Intern Med. 2017 Nov 21;167(10):706–13. doi: 10.7326/m17-0767. Exclusion Code: X4. [PubMed: 29049488] [CrossRef]

216.

Figueroa JF, Lyon Z, Zhou X, et al. Persistence and Drivers of High-Cost Status Among Dual-Eligible Medicare and Medicaid Beneficiaries: An Observational Study. Ann Intern Med. 2018 Oct 16;169(8):528–34. doi: 10.7326/m18-0085. PMID: 30285049. Exclusion Code: X9. [PubMed: 30285049] [CrossRef]

217.

Filippi A, Sessa E, Pecchioli S, et al. Homecare for patients with heart failure in Italy. Ital Heart J. 2005 Jul;6(7):573–7. PMID: 15911164. Exclusion Code: X1. [PubMed: 16274019]

218.

Finkelstein AN. Health care hotspotting: a randomized controlled trial. Abdul Latif Jameel Poverty Action Lab. Cooper University Hospital, Camden, New Jersey: 2014. Exclusion Code: X1.

219.

Fiorentino M, Mulles S, Cue L, et al. High Acuity of Postoperative Consults to Emergency General Surgery at an Urban Safety Net Hospital. J Surg Res. 2021 Jan;257:50–5. doi: 10.1016/j.jss.2020.07.038. PMID: 32008721. Exclusion Code: X1. [PubMed: 32818784] [CrossRef]

220.

Fisher HM, McCabe S. Managing chronic conditions for elderly adults: the VNS CHOICE model. Health Care Financ Rev. 2005 Fall;27(1):33–45. PMID: 16205429. Exclusion Code: X1. [PMC free article: PMC4194907] [PubMed: 17288076]

221.

Fitzpatrick T, Rosella LC, Calzavara A, et al. Looking Beyond Income and Education: Socioeconomic Status Gradients Among Future High-Cost Users of Health Care. Am J Prev Med. 2015 Aug;49(2):161–71. doi: 10.1016/j.amepre.2015.02.018. PMID: 25748258. Exclusion Code: X9. [PubMed: 25960393] [CrossRef]

222.

Flarup L, Moth G, Christensen MB, et al. Chronic-disease patients and their use of out-of-hours primary health care: a cross-sectional study. BMC Fam Pract. 2014 Jun 9;15:114. doi: 10.1186/1471-2296-15-114. PMID: 24801269. Exclusion Code: X1. [PMC free article: PMC4064509] [PubMed: 24912378] [CrossRef]

223.

Fleishman JA, Cohen JW. Using information on clinical conditions to predict high-cost patients. Health Serv Res. 2010 Apr;45(2):532–52. doi: 10.1111/j.1475-6773.2009.01080.x. PMID: 23740662. Exclusion Code: X1. [PMC free article: PMC2838159] [PubMed: 20132341] [CrossRef]

224.

Fleming MD, Shim JK, Yen I, et al. Caring for “Super-utilizers”: Neoliberal Social Assistance in the Safety-net. Med Anthropol Q. 2019 Jun;33(2):173–90. doi: 10.1111/maq.12481. PMID: 30726920. Exclusion Code: X9. [PubMed: 30291726] [CrossRef]

225.

Fleury MJ, Grenier G, Bamvita JM, et al. Professional service utilisation among patients with severe mental disorders. BMC Health Serv Res. 2010 May 27;10:141. doi: 10.1186/1472-6963-10-141. PMID: 20078404. Exclusion Code: X1. [PMC free article: PMC2896947] [PubMed: 20507597] [CrossRef]

226.

Flottemesch TJ, Anderson LH, Solberg LI, et al. Patient-centered medical home cost reductions limited to complex patients. Am J Manag Care. 2012 Nov;18(11):677–86. PMID: 22961756. Exclusion Code: X1. [PubMed: 23198711]

227.

Flowers A, Shade K. Evaluation of a Multidisciplinary Care Coordination Program for Frequent Users of the Emergency Department. Prof Case Manag. 2019 Sep/Oct;24(5):230–9. doi: 10.1097/ncm.0000000000000368. PMID: 29471360. Exclusion Code: X1. [PubMed: 31373952] [CrossRef]

228.

Flynn P, Ridgeway J, Wieland M, et al. Primary care utilization and mental health diagnoses among adult patients requiring interpreters: a retrospective cohort study. J Gen Intern Med. 2013;28(3):386–91. doi: 10.1007/s11606-012-2159-5. PMID: 85715044. Exclusion Code: X4. [PMC free article: PMC3579974] [PubMed: 22782282] [CrossRef]

229.

Foebel AD, Hirdes JP, Heckman GA, et al. A profile of older community-dwelling home care clients with heart failure in Ontario. Chronic Dis Can. 2011 Mar;31(2):49–57. PMID: 21343403. Exclusion Code: X1. [PubMed: 21466754]

230.

Fondow M, Schreiter EZ, Thomas C, et al. Initial examination of characteristics of patients who are high utilizers of an established primary care behavioral health consultation service. Families Systems & Health. 2017 Jun;35(2):184–92. doi: 10.1037/fsh0000266. PMID: WOS:000403442700009. Exclusion Code: X4. [PubMed: 28617019] [CrossRef]

231.

Foo KM, Sundram M, Legido-Quigley H. Facilitators and barriers of managing patients with multiple chronic conditions in the community: a qualitative study. BMC Public Health. 2020 Feb;20(1):15. doi: 10.1186/s12889-020-8375-8. PMID: WOS:000519946500003. Exclusion Code: X6. [PMC free article: PMC7045577] [PubMed: 32106838] [CrossRef]

232.

Ford JD, Trestman RL, Steinberg K, et al. Prospective association of anxiety, depressive, and addictive disorders with high utilization of primary, specialty and emergency medical care. Soc Sci Med. 2004 Jun;58(11):2145–8. doi: 10.1016/j.socscimed.2003.08.017. PMID: 15323413. Exclusion Code: X4. [PubMed: 15047073] [CrossRef]

233.

Ford JD, Trestman RL, Tennen H, et al. Relationship of anxiety, depression and alcohol use disorders to persistent high utilization and potentially problematic under-utilization of primary medical care. Soc Sci Med. 2005 Oct;61(7):1618–25. doi: 10.1016/j.socscimed.2005.03.017. PMID: WOS:000231024400023. Exclusion Code: X1. [PubMed: 16005791] [CrossRef]

234.

Fordyce MA, Doescher MP, Skillman SM. The aging of the rural primary care physician workforce: will some locations be more affected than others? [Seattle, WA]: WWAMI Rural Health Research Center; 2013. Exclusion Code: X1.

235.

Fortin M, Cao Z, Fleury MJ. A typology of satisfaction with mental health services based on Andersen’s behavioral model. Soc Psychiatry Psychiatr Epidemiol. 2018 Jun;53(6):587–95. doi: 10.1007/s00127-018-1498-x. PMID: 27936849. Exclusion Code: X1. [PubMed: 29450599] [CrossRef]

236.

Franco RA, Ashwathnarayan R, Deshpandee A, et al. The high prevalence of restless legs syndrome symptoms in liver disease in an academic-based hepatology practice. J Clin Sleep Med. 2008 Feb 15;4(1):45–9. PMID: 18399957. Exclusion Code: X1. [PMC free article: PMC2276829] [PubMed: 18350962]

237.

Fraze TK, Beidler LB, Briggs ADM, et al. Translating Evidence into Practice: ACOs’ Use of Care Plans for Patients with Complex Health Needs. JGIM: Journal of General Internal Medicine. 2021;36(1):147–53. doi: 10.1007/s11606-020-06122-4. PMID: 148469973. Exclusion Code: X1. [PMC free article: PMC7858720] [PubMed: 33006083] [CrossRef]

238.

Fraze TK, Briggs ADM, Whitcomb EK, et al. Role of Nurse Practitioners in Caring for Patients With Complex Health Needs. Med Care. 2020 Oct;58(10):853–60. doi: 10.1097/mlr.0000000000001364. PMID: WOS:000576505000002. Exclusion Code: X1. [PMC free article: PMC7552908] [PubMed: 32925414] [CrossRef]

239.

Fruhauf J, Schwantzer G, Ambros-Rudolph CM, et al. Pilot study using teledermatology to manage high-need patients with psoriasis. Arch Dermatol. 2010 Feb;146(2):200–1. doi: 10.1001/archdermatol.2009.375. PMID: 20825136. Exclusion Code: X1. [PubMed: 20157037] [CrossRef]

240.

Fuda KK, Immekus R. Frequent users of Massachusetts emergency departments: a statewide analysis. Ann Emerg Med. 2006 Jul;48(1):9–16. doi: 10.1016/j.annemergmed.2006.03.001. PMID: 19487595. Exclusion Code: X4. [PubMed: 16781915] [CrossRef]

241.

Galbraith AA, Meyers DJ, Ross-Degnan D, et al. Long-Term Impact of a Postdischarge Community Health Worker Intervention on Health Care Costs in a Safety-Net System. Health Serv Res. 2017 Dec;52(6):2061–78. doi: 10.1111/1475-6773.12790. PMID: 29130267. Exclusion Code: X1. [PMC free article: PMC5682134] [PubMed: 29130267] [CrossRef]

242.

Gallagher NA, Fox D, Dawson C, et al. Improving care transitions: complex high-utilizing patient experiences guide reform. Am J Manag Care. 2017 Oct 1;23(10):e347–e52. PMID: 28829516. Exclusion Code: X1. [PubMed: 29087639]

243.

Gallagher S. Exploring supportive housing’s impact on health and health care quality among high-cost, high-need populations. Corporation for Supportive Housing 2017. https://www​.commonwealthfund​.org/grants/exploring-supportive-housings-impact-health-and-health-care-quality-among-high-cost-high. Exclusion Code: X7.

244.

Garg T, Young AJ, Kost KA, et al. Burden of multiple chronic conditions among patients with urological cancer. J Urol. 2018 Feb;199(2):543–50. doi: 10.1016/j.juro.2017.08.005. PMID: 29473945. Exclusion Code: X1. [PubMed: 28789948] [CrossRef]

245.

Gastal FL, Andreoli SB, Quintana MI, et al. Predicting the revolving door phenomenon among patients with schizophrenic, affective disorders and non-organic psychoses. Rev Saude Publica. 2000 Jun;34(3):280–5. doi: 10.1590/s0034-89102000000300011. PMID: 10883718. Exclusion Code: X1. [PubMed: 10920451] [CrossRef]

246.

Geisz M. A coalition creates a citywide care management system. Robert Wood Johnson Foundation. Princeton, NJ: 2014. https://www​.rwjf.org​/en/library/research​/2011/01/a-coalition-creates-a-citywide-care-management-system-.html. Exclusion Code: X1.

247.

Gelberg L, Andersen RM, Leake BD. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. Health Serv Res. 2000 Feb;34(6):1273–302. PMID: 10654830. Exclusion Code: X1. [PMC free article: PMC1089079] [PubMed: 10654830]

248.

Geurts J, Palatnick W, Strome T, et al. Frequent users of an inner-city emergency department. Cjem. 2012 Sep;14(5):306–13. PMID: 21491293. Exclusion Code: X1. [PubMed: 22967698]

249.

Giannouchos TV, Kum HC, Foster MJ, et al. Characteristics and predictors of adult frequent emergency department users in the United States: A systematic literature review. J Eval Clin Pract. 2019 Jun;25(3):420–33. doi: 10.1111/jep.13137. PMID: 32589150. Exclusion Code: X7. [PubMed: 31044484] [CrossRef]

250.

Giannouchos TV, Washburn DJ, Kum HC, et al. Predictors of Multiple Emergency Department Utilization Among Frequent Emergency Department Users in 3 States. Med Care. 2020 Feb;58(2):137–45. doi: 10.1097/mlr.0000000000001228. PMID: 31373550. Exclusion Code: X4. [PubMed: 31651740] [CrossRef]

251.

Gingold DB, Pierre-Mathieu R, Cole B, et al. Impact of the Affordable Care Act Medicaid expansion on emergency department high utilizers with ambulatory care sensitive conditions: A cross-sectional study. Am J Emerg Med. 2017 May;35(5):737–42. doi: 10.1016/j.ajem.2017.01.014. PMID: 27008540. Exclusion Code: X1. [PubMed: 28110978] [CrossRef]

252.

Glick M. Systematic approach for treating the medically complex dental patient. Alpha Omegan. 2001 Jul–Aug;94(2):40–3. PMID: 11407062. Exclusion Code: X1. [PubMed: 11480187]

253.

Goldstein KM, Zullig LL, Dedert EA, et al. Telehealth interventions designed for women: an evidence map. J Gen Intern Med. 2018;33(12):2191–200. doi: 10.1007/s11606-018-4655-8. Exclusion Code: X1. [PMC free article: PMC6258612] [PubMed: 30284173] [CrossRef]

254.

Goodell S, Bodenheimer T, Berry-Millett R. Care management of patients with complex health care needs. Robert Wood Johnson Foundation. Princeton, NJ: 2009. https://www​.rwjf.org​/en/library/research​/2009/12/care-management-of-patients-with-complex-health-care-needs.html. Exclusion Code: X1. [PubMed: 22052205]

255.

Goodwin A, Henschen B, Nichols N, et al. Systematic review of interventions targeting high-utilizers of inpatient resources. J Gen Intern Med. 2018;33(2):352. Exclusion Code: X1.

256.

Goodwin A, Henschen BL, O’Dwyer LC, et al. Interventions for frequently hospitalized patients and their effect on outcomes: a systematic review. J Hosp Med. 2018;13(12):853–9. doi: 10.12788/jhm.3090. Exclusion Code: X1. [PubMed: 30379144] [CrossRef]

257.

Gore S, Lind A, Somers SA. Profiles of state innovation: roadmap for improving systems of care for dual eligibles. Hamilton, N.J.: Center for Health Care Strategies, Inc.; 2010. Exclusion Code: X1.

258.

Gottlieb LM, Garcia K, Wing H, et al. Clinical interventions addressing nonmedical health determinants in Medicaid managed care. Am J Manag Care. 2016 May;22(5):370–6. PMID: 27266438. Exclusion Code: X7. [PubMed: 27266438]

259.

Grazioli VS, Moullin JC, Kasztura M, et al. Implementing a case management intervention for frequent users of the emergency department (I-CaM): an effectiveness-implementation hybrid trial study protocol. BMC Health Serv Res. 2019 Jan 11;19(1):28. doi: 10.1186/s12913-018-3852-9. PMID: 30212929. Exclusion Code: X1. [PMC free article: PMC6330435] [PubMed: 30634955] [CrossRef]

260.

Greenberg P, Corey-Lisle PK, Birnbaum H, et al. Economic implications of treatment-resistant depression among employees. Pharmacoeconomics. 2004;22(6):363–73. doi: 10.2165/00019053-200422060-00003. PMID: 12716790. Exclusion Code: X1. [PubMed: 15099122] [CrossRef]

261.

Gregori D, Petrinco M, Barbati G, et al. Extreme regression models for characterizing high-cost patients. J Eval Clin Pract. 2009 Feb;15(1):164–71. doi: 10.1111/j.1365-2753.2008.00976.x. PMID: 23055291. Exclusion Code: X9. [PubMed: 19239597] [CrossRef]

262.

Grembowski D, Schaefer J, Johnson KE, et al. A conceptual model of the role of complexity in the care of patients with multiple chronic conditions. Med Care. 2014 Mar;52 Suppl 3:S7–s14. doi: 10.1097/mlr.0000000000000045. PMID: 24561762. Exclusion Code: X4. [PubMed: 24561762] [CrossRef]

263.

Griffin JL, Yersin M, Baggio S, et al. Characteristics and predictors of mortality among frequent users of an emergency department in Switzerland. Eur J Emerg Med. 2018 Apr;25(2):140–6. doi: 10.1097/mej.0000000000000425. PMID: 30358755. Exclusion Code: X1. [PubMed: 27749377] [CrossRef]

264.

Grinspan ZM, Shapiro JS, Abramson EL, et al. Predicting frequent ED use by people with epilepsy with health information exchange data. Neurology. 2015 Sep 22;85(12):1031–8. doi: 10.1212/wnl.0000000000001944. PMID: 26152468. Exclusion Code: X4. [PMC free article: PMC4603600] [PubMed: 26311752] [CrossRef]

265.

Grover CA, Crawford E, Close RJ. The efficacy of case management on emergency department frequent users: an eight-year observational study. J Emerg Med. 2016 Nov;51(5):595–604. doi: 10.1016/j.jemermed.2016.06.002. PMID: 26784515. Exclusion Code: X1. [PubMed: 27595372] [CrossRef]

266.

Grover CA, Sughair J, Stoopes S, et al. Case management reduces length of stay, charges, and testing in emergency department frequent users. West J Emerg Med. 2018 Mar;19(2):238–44. doi: 10.5811/westjem.2017.9.34710. PMID: 30523008. Exclusion Code: X1. [PMC free article: PMC5851494] [PubMed: 29560049] [CrossRef]

267.

Gruneir A, Cigsar C, Wang X, et al. Repeat emergency department visits by nursing home residents: a cohort study using health administrative data. BMC Geriatr. 2018 Jul 5;18(1):157. doi: 10.1186/s12877-018-0854-8. PMID: 28609191. Exclusion Code: X1. [PMC free article: PMC6034297] [PubMed: 29976135] [CrossRef]

268.

Gudleski GD, Satchidanand N, Dunlap LJ, et al. Predictors of medical and mental health care use in patients with irritable bowel syndrome in the United States. Behav Res Ther. 2017 Jan;88:65–75. doi: 10.1016/j.brat.2016.07.006. PMID: 26002407. Exclusion Code: X1. [PMC free article: PMC5300279] [PubMed: 28110677] [CrossRef]

269.

Gundlapalli A, Hanks M, Stevens SM, et al. It takes a village: a multidisciplinary model for the acute illness aftercare of individuals experiencing homelessness. J Health Care Poor Underserved. 2005 May;16(2):257–72. doi: 10.1353/hpu.2005.0033. PMID: 15937390. Exclusion Code: X3. [PubMed: 15937390] [CrossRef]

270.

Gundlapalli AV, Jones AL, Redd A, et al. Characteristics of the highest users of emergency services in Veterans Affairs hospitals: homeless and non-homeless. Stud Health Technol Inform. 2017;238:24–7. Exclusion Code: X4. [PMC free article: PMC6044274] [PubMed: 28679878]

271.

Gunnarsdottir OS, Rafnsson V. Mortality of the users of a hospital emergency department. Emerg Med J. 2006 Apr;23(4):269–73. doi: 10.1136/emj.2005.026690. PMID: 16445478. Exclusion Code: X1. [PMC free article: PMC2579499] [PubMed: 16549571] [CrossRef]

272.

Gupta ND, Greve J. Overweight and obesity and the utilization of primary care physicians. Health Econ. 2011 Sep;20 Suppl 1:53–67. doi: 10.1002/hec.1711. PMID: 20878846. Exclusion Code: X1. [PubMed: 21351183] [CrossRef]

273.

Gusmano MK, Rodwin VG, Weisz D. Medicare Beneficiaries Living In Housing With Supportive Services Experienced Lower Hospital Use Than Others. Health Aff (Millwood). 2018 Oct;37(10):1562–9. doi: 10.1377/hlthaff.2018.0070. PMID: 30273020. Exclusion Code: X1. [PubMed: 30273020] [CrossRef]

274.

Gyurmey T, Kwiatkowski J. Program of All-Inclusive Care for the Elderly (PACE): Integrating Health and Social Care Since 1973. R I Med J (2013). 2019 Jun 4;102(5):30–2. PMID: 31959926. Exclusion Code: X1. [PubMed: 31167525]

275.

Haas LJ, Spendlove DC, Silver MP. Expanding mental health services to older high-utilizing HMO patients: a pilot study. J Clin Psychol Med Settings. 2001;8(3):189–97. doi: 10.1023/A:1011321704324. PMID: CN-00442641. Exclusion Code: X1. [CrossRef]

276.

Hamblin A. Opportunity knocks to improve care for “super utilizers”. CHCS Blog. Hamilton, New Jersey: Center for Health Care Strategies, Inc.; 2015. Exclusion Code: X1.

277.

Hamblin A. Expanding an inventory of programs serving high-need, high-cost populations. Center for Health Care Strategies 2017. https://hsrproject​.nlm​.nih.gov/view_hsrproj_record/20191185. Exclusion Code: X7.

278.

Hamblin A, Davis R, Hunt K. Outreach to high-need, high-cost individuals: best practices for New York health homes. New York: New York State Health Foundation; 2014. Exclusion Code: X1.

279.

Hammond S. Staying home after discharge: nurse-led versus physician-led transitional care models. Nurse Leader. 2015 Jun;13(3):66-+. doi: 10.1016/j.mnl.2014.09.012. PMID: WOS:000438196100016. Exclusion Code: X1. [CrossRef]

280.

Hand C, McColl MA, Birtwhistle R, et al. Social isolation in older adults who are frequent users of primary care services. Can Fam Physician. 2014 Jun;60(6):e322, e4–9. PMID: 24628805. Exclusion Code: X1. [PMC free article: PMC4055344] [PubMed: 24925967]

281.

Hansagi H, Olsson M, Hussain A, et al. Is information sharing between the emergency department and primary care useful to the care of frequent emergency department users? Eur J Emerg Med. 2008 Feb;15(1):34–9. doi: 10.1097/MEJ.0b013e3282aa4115. PMID: 18459089. Exclusion Code: X1. [PubMed: 18180664] [CrossRef]

282.

Hansagi H, Olsson M, Sjoberg S, et al. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med. 2001 Jun;37(6):561–7. doi: 10.1067/mem.2001.111762. PMID: 11240313. Exclusion Code: X1. [PubMed: 11385324] [CrossRef]

283.

Hardie TL, Polek C, Wheeler E, et al. Characterising emergency department high-frequency users in a rural hospital. Emerg Med J. 2015 Jan;32(1):21–5. doi: 10.1136/emermed-2013-202369. PMID: 25564171. Exclusion Code: X4. [PubMed: 24351523] [CrossRef]

284.

Hardin L, Trumbo S, Murray V. What matters most in driving cross-sector partnerships for complex populations.[webinar]. The National Center for Complex Health and Social Needs; 2019. https://www​.nationalcomplex​.care/research-policy​/resources/webinars​/what-matters-most-in-driving-cross-sector-partnerships-for-complex-populations/. Exclusion Code: X1.

285.

Haroun D, Smits F, van Etten-Jamaludin F, et al. The effects of interventions on quality of life, morbidity and consultation frequency in frequent attenders in primary care: a systematic review. European Journal of General Practice. 2016;22(2):71–82. doi: 10.3109/13814788.2016.1161751. PMID: WOS:000379260000002. Exclusion Code: X1. [PubMed: 27122125] [CrossRef]

286.

Harrison C, Britt H, Miller G, et al. Examining different measures of multimorbidity, using a large prospective cross-sectional study in Australian general practice. BMJ Open. 2014 Jul 11;4(7):e004694. doi: 10.1136/bmjopen-2013-004694. PMID: 24735803. Exclusion Code: X1. [PMC free article: PMC4120329] [PubMed: 25015470] [CrossRef]

287.

Hart KM. Coordinated care of medically complex individuals in an individual-centered medical home: the surprising case of Mr. and Mrs. W. J Am Geriatr Soc. 2015 Jan;63(1):173–4. doi: 10.1111/jgs.13186. PMID: 26378131. Exclusion Code: X1. [PubMed: 25597566] [CrossRef]

288.

Hawes EM, Smith JN, Pinelli NR, et al. Accountable Care in Transitions (ACTion): a team-based approach to reducing hospital utilization in a patient-centered medical home. J Pharm Pract. 2018 Apr;31(2):175–82. doi: 10.1177/0897190017707118. PMID: 29453868. Exclusion Code: X1. [PubMed: 28468524] [CrossRef]

289.

Hawkins EJ, Lott AMK, Malte CA, et al. Patients’ perspectives on care management services for complex substance use disorders. J Addict Dis. 2017 Jul–Sep;36(3):193–206. doi: 10.1080/10550887.2017.1326654. PMID: 28481144. Exclusion Code: X11. [PMC free article: PMC9870041] [PubMed: 28481144] [CrossRef]

290.

Hayes SL, McCarthy D. Care management plus: strengthening primary care for patients with multiple chronic conditions. Commonwealth Fund. 2016. https://www​.commonwealthfund​.org/publications​/case-study/2016​/dec/care-management-plus-strengthening-primary-care-patients-multiple. Exclusion Code: X1.

291.

Hayes SL, Salzberg CA, McCarthy D, et al. High-need, high-cost patients: who are they and how do they use health care? A population-based comparison of demographics, health care use, and expenditures. Issue Brief (Commonw Fund). 2016 Aug;26:1–14. PMID: 27571600. Exclusion Code: X4. [PubMed: 27571599]

292.

Heincelman M, Schumann SO, Riley J, et al. Identification of high utilization inpatients on internal medicine services. Am J Med Sci. 2016 Jul;352(1):63–70. doi: 10.1016/j.amjms.2016.04.020. PMID: 28609191. Exclusion Code: X1. [PubMed: 27432036] [CrossRef]

293.

Hempstead K, Delia D, Cantor JC, et al. The fragmentation of hospital use among a cohort of high utilizers: implications for emerging care coordination strategies for patients with multiple chronic conditions. Med Care. 2014;52:S67–74. doi: 10.1097/MLR.0000000000000049. PMID: 107888969. Language: English. Entry Date: 20140502. Revision Date: 20150712. Publication Type: Journal Article. Exclusion Code: X1. [PubMed: 24561761] [CrossRef]

294.

Hempstead K, Delia D, Cantor JC, et al. Important study on high utilization released. Hotspot Blog. Camden, NJ: Camden Coalition; 2014. Exclusion Code: X4.

295.

Hempstead K, Delia D, Cantor JC, et al. The fragmentation of hospital use among a cohort of high utilizers: implications for emerging care coordination strategies for patients with multiple chronic conditions. Med Care. 2014 Mar;52 Suppl 3:S67–74. doi: 10.1097/mlr.0000000000000049. PMID: 24561761. Exclusion Code: X4. [PubMed: 24561761] [CrossRef]

296.

Henninger DE, Whitson HE, Cohen HJ, et al. Higher medical morbidity burden is associated with external locus of control. J Am Geriatr Soc. 2012 Apr;60(4):751–5. doi: 10.1111/j.1532-5415.2012.03904.x. PMID: 22897676. Exclusion Code: X1. [PMC free article: PMC3325320] [PubMed: 22458257] [CrossRef]

297.

Henschen BL. Understanding perspectives of frequently-admitted hospital patients (CHAMP). Northwestern Memorial Hospital. Chicago: 2017. Exclusion Code: X1.

298.

Henschen BL, Chapman M, Toms A, et al. The complex high admission management program (CHAMP): development and preliminary impact on hospital utilization. J Gen Intern Med. 2017;32(2):S799–S800. PMID: CN-01362537. Exclusion Code: X1.

299.

Henschen BL, Liss DT, Golden B, et al. The education centered medical home improves primary care training and may mitigate burnout: a randomized medical education trial. J Gen Intern Med. 2019;34(2):S370–. doi: 10.1007/11606.1525-1497. PMID: CN-01980331. Exclusion Code: X1. [CrossRef]

300.

Hensel JM, Taylor VH, Fung K, et al. Unique characteristics of high-cost users of medical care with comorbid mental illness or addiction in a population-based cohort. Psychosomatics. 2018 Mar – Apr;59(2):135–43. doi: 10.1016/j.psym.2017.10.005. PMID: 30305053. Exclusion Code: X1. [PubMed: 29157683] [CrossRef]

301.

Hewner S, Chen CH, Anderson L, et al. Transitional Care Models for High-Need, High-Cost Adults in the United States A Scoping Review and Gap Analysis. Professional Case Management. 2021 Mar–Apr;26(2):82–98. doi: 10.1097/ncm.0000000000000442. PMID: WOS:000613200500005. Exclusion Code: X9. [PMC free article: PMC10576263] [PubMed: 32467513] [CrossRef]

302.

Hibbard JH, Greene J, Sacks R, et al. Adding a measure of patient self-management capability to risk assessment can improve prediction of high costs. Health Aff (Millwood). 2016 Mar;35(3):489–94. doi: 10.1377/hlthaff.2015.1031. PMID: 26953304. Exclusion Code: X1. [PubMed: 26953304] [CrossRef]

303.

Hildebrandt DE, Westfall JM, Nicholas RA, et al. Are frequent callers to family physicians high utilizers? Ann Fam Med. 2004;2(6):546–8. doi: 10.1370/afm.127. Exclusion Code: X1. [PMC free article: PMC1466750] [PubMed: 15576539] [CrossRef]

304.

Hochman M, Asch SM. Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations. J Gen Intern Med. 2017 Apr;32(4):392–7. doi: 10.1007/s11606-016-3945-2. PMID: 26344939. Exclusion Code: X1. [PMC free article: PMC5377887] [PubMed: 28243870] [CrossRef]

305.

Horrocks D, Kinzer D, Afzal S, et al. The adequacy of individual hospital data to identify high utilizers and assess community health. JAMA Intern Med. 2016;176(6):856–8. doi: 10.1001/jamainternmed.2016.1248. PMID: 116097739. Language: English. Entry Date: 20180228. Revision Date: 20180413. Publication Type: journal article. Journal Subset: Biomedical. Exclusion Code: X1. [PubMed: 27111673] [CrossRef]

306.

Horvath B, Silberberg M, Landerman LR, et al. Dynamics of patient targeting for care management in medicaid: a case study of the Durham Community Health Network. Care Management Journals. 2006 Fall2006;7(3):107–14. PMID: 106222651. Language: English. Entry Date: 20070126. Revision Date: 20150820. Publication Type: Journal Article. Exclusion Code: X1. [PubMed: 17214243]

307.

Horwood H, Williams MJ, Mandic S. Examining motivations and barriers for attending maintenance community-based cardiac rehabilitation using the health-belief model. Heart Lung Circ. 2015 Oct;24(10):980–7. doi: 10.1016/j.hlc.2015.03.023. PMID: 25795473. Exclusion Code: X1. [PubMed: 25939724] [CrossRef]

308.

Hostetter M, Klein S, McCarthy D. Aging gracefully: the PACE approach to caring for frail elders in the community. [New York, NY]: Commonwealth Fund; 2016. Exclusion Code: X1.

309.

Hostetter M, Klein S, McCarthy D. Project ECHO’s Complex Care Initiative: building capacity to help “superutilizers” in underserved communities. Commonwealth Fund. 2016. https://www​.commonwealthfund​.org/publications​/case-study/2016​/aug/project-echos-complex-care-initiative-building-capacity-help. Exclusion Code: X1.

310.

Hostetter M, Klein S, McCarthy D. CareMore: improving outcomes and controlling health care spending for high-needs patients. Commonwealth Fund. 2017. https://www​.commonwealthfund​.org/publications​/case-study/2017​/mar/caremore-improving-outcomes-and-controlling-health-care-spending. Exclusion Code: X1.

311.

Hostetter M, Klein S, McCarthy D, et al. Guided care: a structured approach to providing comprehensive primary care for complex patients. Commonwealth Fund. 2016. https://www​.commonwealthfund​.org/publications​/case-study/2016​/oct/guided-care-structured-approach-providing-comprehensive-primary. Exclusion Code: X1.

312.

Hsu KY, Slightam C, Shaw JG, et al. High-Need Patients’ Goals and Goal Progress in a Veterans Affairs Intensive Outpatient Care Program. J Gen Intern Med. 2019 Aug;34(8):1564–70. doi: 10.1007/s11606-019-05010-w. PMID: 31283719. Exclusion Code: X1. [PMC free article: PMC6667543] [PubMed: 31140094] [CrossRef]

313.

Hu J, Wang F, Sun J, et al. A healthcare utilization analysis framework for hot spotting and contextual anomaly detection. AMIA. Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2012;2012:360–9. Exclusion Code: X1. [PMC free article: PMC3540544] [PubMed: 23304306]

314.

Hu Z, Hao S, Jin B, et al. Online Prediction of Health Care Utilization in the Next Six Months Based on Electronic Health Record Information: A Cohort and Validation Study. J Med Internet Res. 2015 Sep 22;17(9):e219. doi: 10.2196/jmir.4976. PMID: 26395541. Exclusion Code: X1. [PMC free article: PMC4642374] [PubMed: 26395541] [CrossRef]

315.

Huang JA, Lai CS, Tsai WC, et al. Determining factors of patient satisfaction for frequent users of emergency services in a medical center. J Chin Med Assoc. 2004 Aug;67(8):403–10. PMID: 15889019. Exclusion Code: X1. [PubMed: 15553800]

316.

Huang JA, Tsai WC, Chen YC, et al. Factors associated with frequent use of emergency services in a medical center. J Formos Med Assoc. 2003 Apr;102(4):222–8. PMID: 12449444. Exclusion Code: X1. [PubMed: 12833184]

317.

Huang JA, Weng RH, Tsai WC, et al. Analysis of emergency department utilization by elderly patients under National Health Insurance. Kaohsiung J Med Sci. 2003 Mar;19(3):113–20. doi: 10.1016/s1607-551x(09)70458-9. PMID: 12603227. Exclusion Code: X1. [PubMed: 12751871] [CrossRef]

318.

Huang YY, Cheng SH. A community pharmacist home visit project for high utilizers under a universal health system: a preliminary assessment. Health Policy. 2019;123(4):373–8. doi: 10.1016/j.healthpol.2019.01.011. Exclusion Code: X1. [PubMed: 30739818] [CrossRef]

319.

Hudon C, Chouinard MC, Diadiou F, et al. The Chronic Disease Self-Management Program: the experience of frequent users of health care services and peer leaders. Fam Pract. 2016 Apr;33(2):167–71. doi: 10.1093/fampra/cmw007. PMID: 27401827. Exclusion Code: X1. [PMC free article: PMC4793803] [PubMed: 26984994] [CrossRef]

320.

Hudon C, Chouinard MC, Diadiou F, et al. Case management in primary care for frequent users of health care services with chronic diseases: a qualitative study of patient and family experience. Ann Fam Med. 2015 Nov;13(6):523–8. doi: 10.1370/afm.1867. PMID: 27074709. Exclusion Code: X6. [PMC free article: PMC4639377] [PubMed: 26553891] [CrossRef]

321.

Hudon C, Chouinard MC, Dubois MF, et al. Case management in primary care for frequent users of health care services: a mixed methods study. Ann Fam Med. 2018 May;16(3):232–9. doi: 10.1370/afm.2233. PMID: 30759630. Exclusion Code: X1. [PMC free article: PMC5951252] [PubMed: 29760027] [CrossRef]

322.

Huffstetler AN, Phillips RL. Payment Structures That Support Social Care Integration With Clinical Care: Social Deprivation Indices and Novel Payment Models. Am J Prev Med. 2019 Dec;57(6):S82–S8. doi: 10.1016/j.amepre.2019.07.011. PMID: WOS:000496954300010. Exclusion Code: X1. [PubMed: 31753283] [CrossRef]

323.

Hulen E, Laliberte A, Ono S, et al. “Eyes in the Home”: Addressing Social Complexity in Veterans Affairs Home-Based Primary Care. J Gen Intern Med. 2021 Jan 11. doi: 10.1007/s11606-020-06356-2. Exclusion Code: X1. [PMC free article: PMC8042101] [PubMed: 33432431] [CrossRef]

324.

Humowiecki M, Kuruna T, Sax R, et al. Blueprint for complex care: advancing the field of care for individuals with complex health and social needs. National Center for Complex Health and Social Needs: Center for Health Care Strategies, and Institute for Healthcare Improvement; 2018. Exclusion Code: X7.

325.

Hwang AS, Liu SW, Yelibi C, et al. Characteristics of persistent emergency department high utilizers in a large primary care practice-based research network. J Gen Intern Med. 2014 Apr;29:S47–S. PMID: WOS:000340996200116. Exclusion Code: X4.

326.

Hyer JM, Ejaz A, Diaz A, et al. Characterizing and Assessing the Impact of Surgery on Healthcare Spending Among Medicare Enrolled Preoperative Super-utilizers. Ann Surg. 2019 Sep;270(3):554–63. doi: 10.1097/sla.0000000000003426. PMID: 31140094. Exclusion Code: X1. [PubMed: 31305286] [CrossRef]

327.

Hyer JM, Tsilimigras DI, Gani F, et al. Factors associated with switching between low and super utilization in the surgical population: A study in medicare expenditure. Am J Surg. 2020 Jan;219(1):1–7. doi: 10.1016/j.amjsurg.2019.07.042. PMID: 31835473. Exclusion Code: X9. [PubMed: 31405521] [CrossRef]

328.

International R. Evaluation of Medicare care management for high cost beneficiaries (CMHCB) demonstration second annual report.Centers for Medicare & Medicaid Services; 2008. Exclusion Code: X1.

329.

Iovan S, Lantz PM, Allan K, et al. Interventions to decrease use in prehospital and emergency care settings among super-utilizers in the United States: a systematic review. Med Care Res Rev. 2019 Apr 26:1077558719845722. doi: 10.1177/1077558719845722. Exclusion Code: X1. [PubMed: 31027455] [CrossRef]

330.

Iovan S, Lantz PM, Allan K, et al. Interventions to decrease use in prehospital and emergency care settings among super-utilizers in the United States: a systematic review. Med Care Res Rev. 2020;77(2):99–111. doi: 10.1177/1077558719845722. Exclusion Code: X7. [PubMed: 31027455] [CrossRef]

331.

Isasi F. Helping states achieve sustainable transformation of their health systems. National Governors Association Center for Best Practices: Commonwealth Fund; 2015. Exclusion Code: X7.

332.

Ismail MS, Dagerman K, Tariot PN, et al. National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness- Alzheimer’s Disease (CATIE-AD): baseline characteristics. Curr Alzheimer Res. 2007 Jul;4(3):325–35. PMID: 17490826. Exclusion Code: X1. [PubMed: 17627490]

333.

Jackson TS, Moran TP, Lin J, et al. Homelessness Among Patients in a Southeastern Safety Net Emergency Department. South Med J. 2019 Sep;112(9):476–82. doi: 10.14423/smj.0000000000001016. PMID: 31485585. Exclusion Code: X1. [PubMed: 31485585] [CrossRef]

334.

Jean Scholz Mellum DM, Greer Glazer, Grant Martsolf, Barbara Tobias. A mixed methods study of the experience of older adults with multimorbidity in a Care Coordination Program. International Journal of Care Coordination. 2018. Exclusion Code: X11.

335.

Jiang HJ, Russo A, Barrett M. Nationwide frequency and costs of potentially preventable hospitalizations, 2006. [Rockville, Md.: Agency for Healthcare Research and Quality; 2009. Exclusion Code: X1. [PubMed: 21510033]

336.

Jimenez XF. Attachment in medical care: a review of the interpersonal model in chronic disease management. Chronic Illn. 2017 Mar;13(1):14–27. doi: 10.1177/1742395316653454. PMID: 27132979. Exclusion Code: X1. [PubMed: 27269506] [CrossRef]

337.

Johnson D, Saavedra P, Sun E, et al. Community health workers and medicaid managed care in New Mexico. J Community Health. 2012 Jun;37(3):563–71. doi: 10.1007/s10900-011-9484-1. PMID: 21953498. Exclusion Code: X1. [PMC free article: PMC3343233] [PubMed: 21953498] [CrossRef]

338.

Johnson I. Alcohol problems in old age: a review of recent epidemiological research. Int J Geriatr Psychiatry. 2000 Jul;15(7):575–81. PMID: 10929791. Exclusion Code: X1. [PubMed: 10918336]

339.

Johnson TL, Rinehart DJ, Durfee J, et al. For many patients who use large amounts of health care services, the need is intense yet temporary. Health Aff (Millwood). 2015 Aug;34(8):1312–9. doi: 10.1377/hlthaff.2014.1186. PMID: 22943609. Exclusion Code: X4. [PubMed: 26240244] [CrossRef]

340.

Johnston KJ, Hockenberry JM, Wadhera RK, et al. Clinicians With High Socially At-Risk Caseloads Received Reduced Merit-Based Incentive Payment System Scores. Health Aff (Millwood). 2020 Sep;39(9):1504–12. doi: 10.1377/hlthaff.2020.00350. Exclusion Code: X1. [PubMed: 32897781] [CrossRef]

341.

Johnston KJ, Wen H, Joynt Maddox KE. Inadequate Risk Adjustment Impacts Geriatricians’ Performance on Medicare Cost and Quality Measures. J Am Geriatr Soc. 2020 Feb;68(2):297–304. doi: 10.1111/jgs.16297. PMID: 32178926. Exclusion Code: X1. [PubMed: 31880310] [CrossRef]

342.

Johnston SS, Ammann EM, Kashyap SR, et al. Body mass index and insulin use as identifiers of high-cost patients with type 2 diabetes: A retrospective analysis of electronic health records linked to insurance claims data. Diabetes Obes Metab. 2019 Jun;21(6):1419–28. doi: 10.1111/dom.13671. PMID: 31752866. Exclusion Code: X1. [PubMed: 30768824] [CrossRef]

343.

Jones AL, Thomas R, Hedayati DO, et al. Patient predictors and utilization of health services within a medical home for homeless persons. Subst Abus. 2018;39(3):354–60. doi: 10.1080/08897077.2018.1437500. PMID: 29412071. Exclusion Code: X11. [PubMed: 29412071] [CrossRef]

344.

Jones IR, Ahmed N, Kelly M, et al. With an attack I associate it more with going into hospital: understandings of asthma and psychosocial stressors; are they related to use of services? Soc Sci Med. 2008 Feb;66(3):765–75. doi: 10.1016/j.socscimed.2007.09.012. PMID: 18384440. Exclusion Code: X1. [PubMed: 18006131] [CrossRef]

345.

Jorgenson DJ, Landry EJ, Lysak KJ. A mixed methods evaluation of a patient care clinic located within a pharmacy school. Int J Clin Pharm. 2016 Aug;38(4):924–30. doi: 10.1007/s11096-016-0313-6. PMID: 27067760. Exclusion Code: X1. [PubMed: 27166829] [CrossRef]

346.

Joynt KE, Gawande AA, Orav EJ, et al. Contribution of preventable acute care spending to total spending for high-cost Medicare patients. JAMA. 2013 Jun 26;309(24):2572–8. doi: 10.1001/jama.2013.7103. PMID: 22581227. Exclusion Code: X9. [PubMed: 23797716] [CrossRef]

347.

Jung D, Kind A, Robert S, et al. Linking neighborhood context and health in community-dwelling older adults in the Medicare Advantage program. J Am Geriatr Soc. 2018 Jul;66(6):1158–64. doi: 10.1111/jgs.15366. Exclusion Code: X1. [PMC free article: PMC6105383] [PubMed: 29648689] [CrossRef]

348.

Kadakia K, McClellan M, Udadyakumar K, et al. Adapting promising innovations to meet the needs of high-need, high-cost populations. 2019. https://www​.commonwealthfund​.org/blog/2019​/adapting-promising-innovations-meet-needs-high-need-high-cost-populations. Exclusion Code: X1.

349.

Kang-Lim TJY. Emergency Department: Effectiveness of a Referral Intervention for High Utilizers: George Fox University; 2014. Exclusion Code: X3.

350.

Kaplowitz RA, Scranton RE, Gagnon DR, et al. Health care utilization and receipt of cholesterol testing by veterans with and those without mental illness. Gen Hosp Psychiatry. 2006 Mar–Apr;28(2):137–44. doi: 10.1016/j.genhosppsych.2005.10.002. PMID: 16876547. Exclusion Code: X1. [PubMed: 16516064] [CrossRef]

351.

Kapur N. Frequent attenders in primary care; 2007. Exclusion Code: X1.

352.

Kapur N, Hunt I, MacFarlane G, et al. Childhood experience and health care use in adulthood - nested case-control study. Br J Psychiatry. 2004 Aug;185:134–9. doi: 10.1192/bjp.185.2.134. PMID: WOS:000223206500008. Exclusion Code: X1. [PubMed: 15286064] [CrossRef]

353.

Kaskie B, Wallace N, Kang S, et al. The implementation of managed behavioral healthcare in Colorado and the effects on older Medicaid beneficiaries. J Ment Health Policy Econ. 2006 Mar;9(1):15–24. PMID: 16959131. Exclusion Code: X1. [PubMed: 16733268]

354.

Katon W, Ciechanowski P. Impact of major depression on chronic medical illness. J Psychosom Res. 2002 Oct;53(4):859–63. doi: 10.1016/s0022-3999(02)00313-6. PMID: WOS:000178737100005. Exclusion Code: X1. [PubMed: 12377294] [CrossRef]

355.

Katz A, Martens P, Chateau D, et al. Do primary care physicians coordinate ambulatory care for chronic disease patients in Canada? BMC Fam Pract. 2014 Aug 30;15:148. doi: 10.1186/1471-2296-15-148. PMID: 25047884. Exclusion Code: X1. [PMC free article: PMC4160545] [PubMed: 25175589] [CrossRef]

356.

Kaushal R. Identifying and predicting patients with preventable high utilization. Joan & Sanford I. Weill Medical College of Cornell University. New York: 2017. https://www​.pcori.org​/research-results/2016​/identifying-and-predicting-patients-preventable-high-utilization. Exclusion Code: X7.

357.

Keeney T, Belanger E, Jones RN, et al. High-Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes. J Am Geriatr Soc. 2020 Jan;68(1):70–7. doi: 10.1111/jgs.16146. PMID: 31876646. Exclusion Code: X1. [PMC free article: PMC6952536] [PubMed: 31454082] [CrossRef]

358.

Kehusmaa S, Autti-Ramo I, Helenius H, et al. Factors associated with the utilization and costs of health and social services in frail elderly patients. BMC Health Serv Res. 2012 Jul 19;12:204. doi: 10.1186/1472-6963-12-204. PMID: 22486678. Exclusion Code: X1. [PMC free article: PMC3476428] [PubMed: 22812588] [CrossRef]

359.

Ken Coburn CG, Sophia Demuynck, Margaret Hawthorne. Replicating Effective Models Of Complex Care Management For Older Adults. Health Affairs Blog; 2017. Exclusion Code: X1.

360.

Kern L. Developing indicators of care fragmentation that predict service utilization by high-need, high-cost patients. Cornell University, Weill Cornell Medical College, Department of Healthcare Policy and Research 2015. https://www​.ajmc.com​/journals/issue/2018​/2018-vol24-n9/fragmented-ambulatory-care-and-subsequent-healthcare-utilization-among-medicare-beneficiaries?p=4. Exclusion Code: X7.

361.

Kim JJ, Kwok ESH, Cook OG, et al. Characterizing highly frequent users of a large Canadian urban emergency department. West J Emerg Med. 2018 Nov;19(6):926–33. doi: 10.5811/westjem.2018.9.39369. PMID: 27749377. Exclusion Code: X1. [PMC free article: PMC6225932] [PubMed: 30429923] [CrossRef]

362.

Kim TY, Mortensen K, Eldridge B. Linking uninsured patients treated in the emergency department to primary care shows some promise in Maryland. Health Aff (Millwood). 2015 May;34(5):796–804. doi: 10.1377/hlthaff.2014.1102. PMID: 25639993. Exclusion Code: X1. [PubMed: 25941281] [CrossRef]

363.

Kimmel HJ, Brice YN, Trikalinos TA, et al. Real-time emergency department electronic notifications regarding high-risk patients: a systematic review. Telemedicine and e-Health. 2019;25(7):604–18. doi: 10.1089/tmj.2018.0117. Exclusion Code: X1. [PMC free article: PMC6664825] [PubMed: 30129886] [CrossRef]

364.

Kirk C. Telephone follow-up of older people after hospital admissions. Curr Aging Sci. 2014;7(2):144–53. PMID: 24588292. Exclusion Code: X1. [PubMed: 25101710]

365.

Kirkpatrick S, Agana DFG, Lynch K, et al. Emergency department high utilizers among family medicine patients. J Am Board Fam Med. 2019;32(2):264–8. doi: 10.3122/jabfm.2019.02.180184. Exclusion Code: X4. [PubMed: 30850463] [CrossRef]

366.

Klein S, Hostetter M, McCarthy D. Bringing primary care home: the medical house call program at MedStar Washington Hospital Center. Commonwealth Fund. 2016. https://www​.commonwealthfund​.org/publications​/case-study/2016​/jul/bringing-primary-care-home-medical-house-call-program-medstar. Exclusion Code: X1.

367.

Klein S, Hostetter M, McCarthy D. The “one care” program at Commonwealth Care Alliance. Commonwealth Fund. 2016. https://www​.commonwealthfund​.org/publications​/case-study/2016​/dec/one-care-program-commonwealth-care-alliance. Exclusion Code: X1.

368.

Klein S, Hostetter M, McCarthy D. Caring for high-need, high-cost patients: exemplars from the field. 2016. https://www​.commonwealthfund​.org/blog/2016​/caring-high-need-high-cost-patients-exemplars-field. Exclusion Code: X1.

369.

Klompstra L, Ekdahl AW, Krevers B, et al. Factors related to health-related quality of life in older people with multimorbidity and high health care consumption over a two-year period. BMC Geriatr. 2019 Jul 5;19(1):187. doi: 10.1186/s12877-019-1194-z. PMID: 30827894. Exclusion Code: X6. [PMC free article: PMC6612189] [PubMed: 31277674] [CrossRef]

370.

Knowlton A, Weir BW, Hughes BS, et al. Patient demographic and health factors associated with frequent use of emergency medical services in a midsized city. Acad Emerg Med. 2013 Nov;20(11):1101–11. doi: 10.1111/acem.12253. PMID: 25287826. Exclusion Code: X4. [PMC free article: PMC4063348] [PubMed: 24238312] [CrossRef]

371.

Knox K, Schneider J, Gatmaitan V, et al. Breaking the cycle: a successful intervention for high utilizers on a general medicine service. J Gen Intern Med. 2017 Apr;32:S738–S9. PMID: WOS:000440259003121. Exclusion Code: X1.

372.

Ko FW, Dai DL, Ngai J, et al. Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD. Respirology. 2011 May;16(4):617–24. doi: 10.1111/j.1440-1843.2010.01921.x. PMID: 21734226. Exclusion Code: X1. [PubMed: 21199163] [CrossRef]

373.

Ko M, Lee Y, Chen C, et al. Prevalence of and predictors for frequent utilization of emergency department: a population-based study. Medicine (Baltimore). 2015 Jul;94(29):e1205. doi: 10.1097/md.0000000000001205. PMID: 25956826. Exclusion Code: X1. [PMC free article: PMC4603019] [PubMed: 26200638] [CrossRef]

374.

Koball AM, Rasmussen C, Olson-Dorff D, et al. The relationship between adverse childhood experiences, healthcare utilization, cost of care and medical comorbidities. Child Abuse Negl. 2019;90:120–6. doi: 10.1016/j.chiabu.2019.01.021. Exclusion Code: X1. [PubMed: 30776737] [CrossRef]

375.

Koch KL, Karafin MS, Simpson P, et al. Intensive management of high-utilizing adults with sickle cell disease lowers admissions. Am J Hematol. 2015 Mar;90(3):215–9. doi: 10.1002/ajh.23912. PMID: 23058483. Exclusion Code: X4. [PubMed: 25469750] [CrossRef]

376.

KPMG Government Institute. Investing in social services as a core strategy for healthcare organizations: developing the business case. Commonwealth Fund. 2018. https://www​.commonwealthfund​.org/publications​/other-publication​/2018/mar/investing-social-services-core-strategy-healthcare. Exclusion Code: X1.

377.

Kramer W. How employers are improving care and lowering costs for complex patients. Commonwealth Fund; 2016. Exclusion Code: X1.

378.

Kreuter MW, Garg R, Li L, et al. How Do Social Needs Cluster Among Low-Income Individuals? Popul Health Manag. 2020 Sep 1. doi: 10.1089/pop.2020.0107. PMID: 32877298. Exclusion Code: X11. [PMC free article: PMC8215422] [PubMed: 32877298] [CrossRef]

379.

Krieg C, Hudon C, Chouinard MC, et al. Individual predictors of frequent emergency department use: a scoping review. BMC Health Serv Res. 2016 Oct 20;16(1):594. doi: 10.1186/s12913-016-1852-1. PMID: 27756416. Exclusion Code: X1. [PMC free article: PMC5072329] [PubMed: 27765045] [CrossRef]

380.

Kromka W, Simpson S. A Narrative Review of Predictors of Adult Mental Health Emergency Department Return Visits and Interventions to Reduce Repeated Use. J Emerg Med. 2019 Nov;57(5):671–82. doi: 10.1016/j.jemermed.2019.08.005. PMID: 31270786. Exclusion Code: X7. [PubMed: 31610908] [CrossRef]

381.

Krupski BJCDMCZA. Predictive Risk Intelligence System (Prism): A Decision-Support Tool for Coordinating Care for Complex Medicaid Client. Comprehensive Care Coordination for Chronically Ill Adults. 2011. Exclusion Code: X11.

382.

Ku BS, Fields JM, Santana A, et al. The urban homeless: super-users of the emergency department. Popul Health Manag. 2014 Dec;17(6):366–71. doi: 10.1089/pop.2013.0118. PMID: 28602485. Exclusion Code: X4. [PubMed: 24865472] [CrossRef]

383.

Kuek BJW, Li H, Yap S, et al. Characteristics of frequent users of emergency medical services in Singapore. Prehosp Emerg Care. 2019 Mar–Apr;23(2):215–24. doi: 10.1080/10903127.2018.1484969. PMID: 30458798. Exclusion Code: X1. [PubMed: 30118627] [CrossRef]

384.

Kujanp T, Ylisaukko-Oja T, Jokelainen J, et al. Prevalence of anxiety disorders among Finnish primary care high utilizers and validation of Finnish translation of GAD-7 and GAD-2 screening tools. Scand J Prim Health Care. 2014;32(2):78–83. doi: 10.3109/02813432.2014.920597. PMID: 103964008. Language: English. Entry Date: 20140620. Revision Date: 20151123. Publication Type: Journal Article. Exclusion Code: X1. [PMC free article: PMC4075021] [PubMed: 24920316] [CrossRef]

385.

Kuluski K, Gandhi S, Diong C, et al. Patterns of community follow-up, subsequent health service use and survival among young and mid-life adults discharged from chronic care hospitals: a retrospective cohort study. BMC Health Serv Res. 2016 Aug 13;16(1):382. doi: 10.1186/s12913-016-1631-z. PMID: 27042746. Exclusion Code: X1. [PMC free article: PMC4983410] [PubMed: 27522347] [CrossRef]

386.

Kumar GS, Klein R. Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: a systematic review. J Emerg Med. 2013 Mar;44(3):717–29. doi: 10.1016/j.jemermed.2012.08.035. PMID: WOS:000315946900033. Exclusion Code: X1. [PubMed: 23200765] [CrossRef]

387.

Kurdyak P, Newman A, Segal Z. Impact of mindfulness-based cognitive therapy on health care utilization: a population-based controlled comparison. J Psychosom Res. 2014;77(2):85–9. doi: 10.1016/j.jpsychores.2014.06.009. PMID: CN-00998955. Exclusion Code: X1. [PubMed: 25077847] [CrossRef]

388.

Kurpas D, Szwamel K, Mroczek B. Frequent attenders with chronic respiratory diseases in primary care settings. 2016. p. 17–29. Exclusion Code: X1. [PubMed: 27573642]

389.

Kwakkenbos L, Bluyssen SJ, Vonk MC, et al. Addressing patient health care demands in systemic sclerosis: pre-post assessment of a psycho-educational group programme. Clin Exp Rheumatol. 2011 Mar–Apr;29(2 Suppl 65):S60–5. PMID: 22096551. Exclusion Code: X1. [PubMed: 21586220]

390.

Labby D, Wright B, Broffman L, et al. Drivers of High-cost Medical Complexity in a Medicaid Population. Med Care. 2020 Mar;58(3):208–15. doi: 10.1097/mlr.0000000000001261. PMID: 31584961. Exclusion Code: X9. [PMC free article: PMC7017939] [PubMed: 31876646] [CrossRef]

391.

LaCalle E, Rabin E. Frequent users of emergency departments: the myths, the data, and the policy implications. Ann Emerg Med. 2010 Jul;56(1):42–8. doi: 10.1016/j.annemergmed.2010.01.032. PMID: 20346540. Exclusion Code: X1. [PubMed: 20346540] [CrossRef]

392.

LaFleur J, Fowler MA, McBeth C, et al. Incidence of drug-related problems among Medicaid high utilizers as identified by clinically-trained pharmacist reviewers. Pharmacotherapy. 2005 Mar;25(3):472-. PMID: WOS:000227288900111. Exclusion Code: X1.

393.

LaFleur J, McBeth C, Gunning K, et al. Prevalence of drug-related problems and cost-savings opportunities in Medicaid high utilizers identified by a pharmacist-run drug regimen review center. J Manag Care Pharm. 2006;12(8):677–85. doi: 10.18553/jmcp.2006.12.8.677. Exclusion Code: X1. [PMC free article: PMC10438027] [PubMed: 17269846] [CrossRef]

394.

Lally K, Tuya Fulton A, Ducharme C, et al. Using Nurse Care Managers Trained in the Serious Illness Conversation Guide to Increase Goals-of-Care Conversations in an Accountable Care Organization. J Palliat Med. 2020;23(1):112–5. doi: 10.1089/jpm.2019.0110. Exclusion Code: X1. [PubMed: 31081710] [CrossRef]

395.

Lantz PM. “Super-utilizer” interventions: what they reveal about evaluation research, wishful thinking, and health equity. Milbank Q. 2020 Feb 7. doi: 10.1111/1468-0009.12449. PMID: 32030820. Exclusion Code: X1. [PMC free article: PMC7077764] [PubMed: 32030820] [CrossRef]

396.

Lauffenburger JC, Mahesri M, Choudhry NK. Not there yet: using data-driven methods to predict who becomes costly among low-cost patients with type 2 diabetes. BMC Endocr Disord. 2020;20(1):N.PAG-N.PAG. doi: 10.1186/s12902-020-00609-1. PMID: 145256772. Exclusion Code: X9. [PMC free article: PMC7433196] [PubMed: 32807156] [CrossRef]

397.

Law DD, Crane DR, Berge JM. The influence of individual, marital, and family therapy on high utilizers of health care. J Marital Fam Ther. 2003 Jul;29(3):353–63. PMID: 15241664. Exclusion Code: X1. [PubMed: 12870409]

398.

LaWall E, Wu YY, Fan VY, et al. Living Alone and Homelessness as Predictors of 30-Day Potentially Preventable Hospital Readmission. Prev Chronic Dis. 2019 Feb 7;16:E16. doi: 10.5888/pcd16.180189. PMID: 30730829. Exclusion Code: X1. [PMC free article: PMC6395076] [PubMed: 30730829] [CrossRef]

399.

LeClair AM, Sweeney M, Yoon GH, et al. Patients’ Perspectives on Reasons for Unplanned Readmissions. J Healthc Qual. 2019 Jul/Aug;41(4):237–42. doi: 10.1097/jhq.0000000000000160. PMID: 31651740. Exclusion Code: X1. [PubMed: 30180043] [CrossRef]

400.

Ledoux Y, Minner P. Occasional and frequent repeaters in a psychiatric emergency room. Soc Psychiatry Psychiatr Epidemiol. 2006 Feb;41(2):115–21. doi: 10.1007/s00127-005-0010-6. PMID: 16982382. Exclusion Code: X1. [PubMed: 16508721] [CrossRef]

401.

Lee JY, Muratov S, Tarride JE, et al. Managing High-Cost Healthcare Users: The International Search for Effective Evidence-Supported Strategies. J Am Geriatr Soc. 2018 May;66(5):1002–8. doi: 10.1111/jgs.15257. PMID: 29398469. Exclusion Code: X6. [PubMed: 29427509] [CrossRef]

402.

Lee KH, Davenport L. Can case management interventions reduce the number of emergency department visits by frequent users? Health Care Manag (Frederick). 2006 Apr–Jun;25(2):155–9. PMID: 17150058. Exclusion Code: X1. [PubMed: 16699330]

403.

Legault F, Humbert J, Amos S, et al. Difficulties encountered in collaborative care: logistics trumps desire. J Am Board Fam Med. 2012 Mar–Apr;25(2):168–76. doi: 10.3122/jabfm.2012.02.110153. PMID: 21614451. Exclusion Code: X1. [PubMed: 22403197] [CrossRef]

404.

Legramante JM, Morciano L, Lucaroni F, et al. Frequent use of emergency departments by the elderly population when continuing care is not well established. PLoS One. 2016;11(12):e0165939. doi: 10.1371/journal.pone.0165939. PMID: 25753453. Exclusion Code: X1. [PMC free article: PMC5156362] [PubMed: 27973563] [CrossRef]

405.

Leininger L, Avery K. The capacity of self-reported health measures to predict high-need Medicaid enrollees. Princeton, NJ: Robert Wood Johnson Foundation; 2015. Exclusion Code: X4.

406.

Leininger LJ, Friedsam D, Voskuil K, et al. Predicting high-need cases among new Medicaid enrollees. Am J Manag Care. 2014 Sep 1;20(9):e399–407. PMID: 23636712. Exclusion Code: X1. [PubMed: 25364876]

407.

Lenz O, Sadhu S, Fornoni A, et al. Overutilization of central venous catheters in incident hemodialysis patients: reasons and potential resolution strategies. Semin Dial. 2006 Nov–Dec;19(6):543–50. doi: 10.1111/j.1525-139X.2006.00220.x. PMID: 19265720. Exclusion Code: X1. [PubMed: 17150058] [CrossRef]

408.

Leporatti L, Ameri M, Trinchero C, et al. Targeting frequent users of emergency departments: prominent risk factors and policy implications. Health Policy. 2016 May;120(5):462–70. doi: 10.1016/j.healthpol.2016.03.005. PMID: 27046165. Exclusion Code: X1. [PubMed: 27033015] [CrossRef]

409.

Levin S, Brown D, Hernandez E. Contra Costa Health Services whole person care (CommunityConnect) program evaluation (CCHS-WPC). Contra Costa Health Services. 2019. https:​//clinicaltrials​.gov/ct2/show/record​/NCT04000074?term=NCT04000074&draw​=2&rank=1. Exclusion Code: X7.

410.

Levinson CM, Druss BG. Health beliefs and depression in a group of elderly high utilizers of medical services. Gen Hosp Psychiatry. 2005;27(2):97–9. doi: 10.1016/j.genhosppsych.2004.09.010. Exclusion Code: X4. [PubMed: 15763120] [CrossRef]

411.

Levy C, Balogh S, Perkins E. Realizing the potential of rehabilitative care for people with complex health conditions: the time is now. Healthc Q. 2016;19(2):49–54. PMID: 27591400. Exclusion Code: X1. [PubMed: 27700974]

412.

Lewis C, Shah A, Abrams MK, et al. Sick and struggling: high-need adults with financial difficulties have worse access to the quality care they need. 2018. https://www​.commonwealthfund​.org/blog/2018​/sick-and-struggling-high-need-adults-financial-difficulties-have-worse-access-quality. Exclusion Code: X4.

413.

Lewis C, Shah T, Abrams MK. Sick and alone: high-need, socially isolated adults have more problems, but less support. Commonwealth Fund. 2018. https://www​.commonwealthfund​.org/blog/2018​/sick-and-alone-high-need-socially-isolated-adults-have-more-problems-less-support. Exclusion Code: X1.

414.

Lewis VA, Larson BK, McClurg AB, et al. The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles. Health Aff (Millwood). 2012 Aug;31(8):1777–85. doi: 10.1377/hlthaff.2012.0490. PMID: 22869656. Exclusion Code: X1. [PubMed: 22869656] [CrossRef]

415.

Li DR, Brennan JJ, Kreshak AA, et al. Patients Who Leave the Emergency Department Without Being Seen and Their Follow-Up Behavior: A Retrospective Descriptive Analysis. J Emerg Med. 2019;57(1):106–13. doi: 10.1016/j.jemermed.2019.03.051. Exclusion Code: X9. [PubMed: 31078346] [CrossRef]

416.

Li Z, Newton-Dame R, Tatem K, et al. Homegrown safety net system predictive model for risk stratification: Assessing potential racial bias. Health Serv Res. 2020;55(SUPPL 1):76. doi: 10.1111/1475-6773.13435. Exclusion Code: X1. [CrossRef]

417.

Lichtenberg P, Levinson D, Sharshevsky Y, et al. Clinical case management of revolving door patients - a semi-randomized study. Acta Psychiatr Scand. 2008 Jun;117(6):449–54. doi: 10.1111/j.1600-0447.2008.01170.x. PMID: 18185500. Exclusion Code: X4. [PubMed: 18331577] [CrossRef]

418.

Lim A, Warning W. The role of a pharmacist in a super-utilizer care coordination team. Journal of Interprofessional Education and Practice. 2016;3:23–7. doi: 10.1016/j.xjep.2016.03.007. Exclusion Code: X1. [CrossRef]

419.

Lin S, Zhang Q, Chen F, et al. Smooth Bayesian network model for the prediction of future high-cost patients with COPD. Int J Med Inform. 2019 Jun;126:147–55. doi: 10.1016/j.ijmedinf.2019.03.017. PMID: 29211140. Exclusion Code: X6. [PubMed: 31029256] [CrossRef]

420.

Lin WC, Bharel M, Zhang J, et al. Frequent emergency department visits and hospitalizations among homeless people with Medicaid: implications for Medicaid expansion. Am J Public Health. 2015 Nov;105(Suppl 5):S716–22. doi: 10.2105/ajph.2015.302693. PMID: 26223659. Exclusion Code: X1. [PMC free article: PMC4627525] [PubMed: 26447915] [CrossRef]

421.

Lindsay A, Hibbard JH, Boothroyd DB, et al. Patient activation changes as a potential signal for changes in health care costs: cohort study of US high-cost patients. J Gen Intern Med. 2018;33(12):2106–12. doi: 10.1007/s11606-018-4657-6. Exclusion Code: X9. [PMC free article: PMC6258627] [PubMed: 30291604] [CrossRef]

422.

Lines L, Ash A. Predictors of potentially avoidable emergency department visits: a systematic review. 2012. Exclusion Code: X7.

423.

Lipsitt DR. Characteristics of patient–doctor relationships with somatizing patients. International Congress Series. 2006;1287:374–7. doi: 10.1016/j.ics.2005.12.036. PMID: 20918417. Exclusion Code: X1. [CrossRef]

424.

Liss DT, Schaeffer-Pettigrew C, Finch E, et al. A randomized comparative effectiveness trial of a transitional care clinic: 180-day effects. J Gen Intern Med. 2017;32(2):S100. Exclusion Code: X1. [PMC free article: PMC6712181] [PubMed: 31144279]

425.

Little P, Somerville J, Williamson I, et al. Psychosocial, lifestyle, and health status variables in predicting high attendance among adults. Br J Gen Pract. 2001 Dec;51(473):987–94. PMID: 16274019. Exclusion Code: X1. [PMC free article: PMC1314191] [PubMed: 11766871]

426.

Lloyd J. Opportunities to Advance Complex Care in Rural and Frontier Areas. . Center for Health Care Strategies. 2019. https://www​.chcs.org​/resource/opportunities-to-advance-complex-care-in-rural-and-frontier-areas​/?utm_source​=CHCS+Email+Updates&utm​_campaign​=9c4f67c292-TCC+Rural+brief+05​%2F09​%2F19&utm_medium​=email&utm_term​=0_bbced451bf-9c4f67c292-157172209. Exclusion Code: X7.

427.

Locke SE, Ford P, McLaughlin T. A comparative cost analysis of participating versus non-participating somatizing patients referred to a behavioral medicine group in a health maintenance organization. Disease Management & Health Outcomes. 2003;11(5):327–35. PMID: 106078697. Language: English. Entry Date: 20070101. Revision Date: 20150711. Publication Type: Journal Article. Journal Subset: Health Services Administration. Exclusion Code: X1.

428.

Locker TE, Baston S, Mason SM, et al. Defining frequent use of an urban emergency department. Emerg Med J. 2007 Jun;24(6):398–401. doi: 10.1136/emj.2006.043844. PMID: 19632544. Exclusion Code: X1. [PMC free article: PMC2658272] [PubMed: 17513534] [CrossRef]

429.

Loeb DF, Monson SP, Lockhart S, et al. Mixed method evaluation of Relational Team Development (RELATED) to improve team-based care for complex patients with mental illness in primary care. BMC Psychiatry. 2019;19. doi: 10.1186/s12888-019-2294-1. PMID: 2019-62385-001. Exclusion Code: X1. [PMC free article: PMC6792180] [PubMed: 31615460] [CrossRef]

430.

Long P. An untapped opportunity for health care progress: redesigning care for high-need patients. Health Affairs BLOG. Bethesda, MD: Health Affairs; 2018. Exclusion Code: X1.

431.

Low LL, Vasanwala FF, Ng LB, et al. Effectiveness of a transitional home care program in reducing acute hospital utilization: a quasi-experimental study. BMC Health Serv Res. 2015 Mar 14;15:100. doi: 10.1186/s12913-015-0750-2. PMID: 25857588. Exclusion Code: X1. [PMC free article: PMC4377016] [PubMed: 25888830] [CrossRef]

432.

Luciano JV, Fernandez A, Pinto-Meza A, et al. Frequent attendance in primary care: comparison and implications of different definitions. Br J Gen Pract. 2010 Feb;60(571). doi: 10.3399/bjgp10X483139. PMID: WOS:000275978500008. Exclusion Code: X1. [PMC free article: PMC2814289] [PubMed: 20132693] [CrossRef]

433.

Lyles JS, Hodges A, Collins C, et al. Using nurse practitioners to implement an intervention in primary care for high-utilizing patients with medically unexplained symptoms. Gen Hosp Psychiatry. 2003 Mar–Apr;25(2):63–73. PMID: 14631698. Exclusion Code: X4. [PubMed: 12676418]

434.

Machlin SR, Cohen SB, Yu W. Health care access and expenditures among non-elderly adults with multiple chronic conditions: variations by insurance coverage status, 2007–08 (average annual). [Rockville, Md.: Agency for Healthcare Research and Quality; 2011. Exclusion Code: X4.

435.

Mackelprang JL, Collins SE, Clifasefi SL. Housing first is associated with reduced use of emergency medical services. Prehosp Emerg Care. 2014;18(4):476–82. doi: 10.3109/10903127.2014.916020. PMID: 103891579. Language: English. Entry Date: 20140925. Revision Date: 20160325. Publication Type: Journal Article. Exclusion Code: X1. [PMC free article: PMC5102506] [PubMed: 24878364] [CrossRef]

436.

Maeng DD, Hao J, Bulger JB. Patterns of multiple emergency department visits: do primary care physicians matter? Perm J. 2017;21:16–063. doi: 10.7812/tpp/16-063. PMID: 28143506. Exclusion Code: X4. [PMC free article: PMC5363893] [PubMed: 28333606] [CrossRef]

437.

Maier T. Psychosocial and psychodynamic factors influencing health care utilisation. Health Care Anal. 2006 Jun;14(2):69–78. doi: 10.1007/s10728-006-0013-9. PMID: WOS:000242461900001. Exclusion Code: X1. [PubMed: 17195575] [CrossRef]

438.

Malmstrom T, Peltokorpi A, Lappalainen M, et al. Constructing a framework to manage high utilizers in health and social care; 2015. Exclusion Code: X1.

439.

Malone DK, Collins SE, Clifasefi SL. Single-site housing first for chronically homeless people. Housing, Care and Support. 2015;18(2):62–6. doi: 10.1108/HCS-05-2015-0007. Exclusion Code: X1. [PMC free article: PMC3969126] [PubMed: 24148063] [CrossRef]

440.

. Identifying Super Utilizers CHCS Super-Utilizer Summit; 2013. 11585. Exclusion Code: X1.

441.

Mancuso D. Supporting Delivery System Transformation Through Data Integration and Analytics. 2016. https://www​.milbank.org​/resources/supporting-delivery-system-transformation-data-integration-analytics-2/. Exclusion Code: X4.

442.

Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med. 2000 Jun;7(6):637–46. doi: 10.1111/j.1553-2712.2000.tb02037.x. PMID: 10905642. Exclusion Code: X1. [PubMed: 10905642] [CrossRef]

443.

Mantwill S, Schulz PJ. Low health literacy and healthcare utilization among immigrants and non-immigrants in Switzerland. Patient Educ Couns. 2017 Nov;100(11):2020–7. doi: 10.1016/j.pec.2017.05.023. PMID: 28542870. Exclusion Code: X1. [PubMed: 28559092] [CrossRef]

444.

Margaret Trinity MBD, and Michael Bailit, Bailit Health. Integrating Health Care and Social Services: Moving from Concept to Practice. State Health & Value Strategies 2016. Exclusion Code: X7.

445.

Martin BC, Ganguly R, Pannicker S, et al. Utilization patterns and net direct medical cost to Medicaid of irritable bowel syndrome. Curr Med Res Opin. 2003;19(8):771–80. doi: 10.1185/030079903125002540. PMID: 14527870. Exclusion Code: X1. [PubMed: 14687449] [CrossRef]

446.

Martin J, Martin A, Schultz C, et al. Innovations in care delivery: embedding civil legal aid services in care for high-utilizing patients using medical-legal partnership. Health Affairs BLOG. Bethesda, Maryland: Health Affairs; 2015. Exclusion Code: X1.

447.

Master RJ, Eng C. Integrating acute and long-term care for high-cost populations. Health Aff (Millwood). 2001 Nov–Dec;20(6):161–72. doi: 10.1377/hlthaff.20.6.161. PMID: 15338802. Exclusion Code: X9. [PubMed: 11816654] [CrossRef]

448.

Mate K. High-need, high-cost playbook version 3.0. Institute for Healthcare Improvement 2018. https://hsrproject​.nlm​.nih.gov/view_hsrproj_record/20191318. Exclusion Code: X7.

449.

Mateo-Abad M, Fullaondo A, Merino M, et al. Impact Assessment of an Innovative Integrated Care Model for Older Complex Patients with Multimorbidity: The CareWell Project. International Journal of Integrated Care. 2020 Apr–Jun;20(2):11. doi: 10.5334/ijic.4711. PMID: WOS:000550985100005. Exclusion Code: X6. [PMC free article: PMC7243835] [PubMed: 32477037] [CrossRef]

450.

Mathews SN, Lamm R, Yang J, et al. Factors associated with repeated health resource utilization in patients with diverticulitis. J Gastrointest Surg. 2017 Jan;21(1):112–20. doi: 10.1007/s11605-016-3245-5. PMID: 27882804. Exclusion Code: X4. [PubMed: 27613732] [CrossRef]

451.

Mautner D, Peterson B, Cunningham A, et al. How Multidimensional Health Locus of Control predicts utilization of emergency and inpatient hospital services. J Health Psychol. 2017 Mar;22(3):314–23. doi: 10.1177/1359105315603468. PMID: 28559092. Exclusion Code: X1. [PubMed: 26430065] [CrossRef]

452.

McCabe BK, Potash D, Omohundro E, et al. Seven-month pilot of an integrated, continuous evaluation, and quality improvement system for a state-based home-visiting program. Matern Child Health J. 2012 Oct;16(7):1401–12. doi: 10.1007/s10995-011-0905-7. PMID: 23086065. Exclusion Code: X1. [PubMed: 22246712] [CrossRef]

453.

McCarthy D, Ryan J, Klein S. Models of care for high-need, high-cost patients: an evidence synthesis. Commonwealth Fund. 2015. https://www​.commonwealthfund​.org/publications​/issue-briefs/2015​/oct/models-care-high-need-high-cost-patients-evidence-synthesis. Exclusion Code: X1. [PubMed: 26591906]

454.

McConville S, Raven MC, Sabbagh SH, et al. Frequent emergency department users: a statewide comparison before and after Affordable Care Act implementation. Health Aff (Millwood). 2018 Jun;37(6):881–9. doi: 10.1377/hlthaff.2017.0784. PMID: 28884248. Exclusion Code: X4. [PubMed: 29863931] [CrossRef]

455.

McGarrahan AG. A comparison of psychosocial and health characteristics of medical high utilizers and medical low utilizers in primary health care: ProQuest Information & Learning; 2001. Exclusion Code: X1.

456.

McHugh J, Belanger E, Manning D, et al. The care of high-need patient populations: Findings from a 2 year study of high-performing hospitals. Implement Sci. 2020 May;15:2. PMID: WOS:000533323500049. Exclusion Code: X9.

457.

McKenzie R, Williamson M, Roberts R. Who uses the ‘after hours GP helpline’? A profile of users of an after-hours primary care helpline. Aust Fam Physician. 2016 May;45(5):313–8. PMID: 26407631. Exclusion Code: X1. [PubMed: 27166469]

458.

McLeod CC. Initial Assessment of High Utilizers of Emergency Department Services. Shepherd University, ProQuest Dissertations Publishing,; 2018. Exclusion Code: X3.

459.

McMahon CG, Power Foley M, Robinson D, et al. High prevalence of frequent attendance in the over 65s. Eur J Emerg Med. 2018 Feb;25(1):53–7. doi: 10.1097/mej.0000000000000406. PMID: 29157447. Exclusion Code: X1. [PubMed: 27139928] [CrossRef]

460.

Mechanic R. Testing strategies to improve healthcare for high-need, high-cost (HNHC) individuals: planning phase. Institute for Accountable Care 2018. https://hsrproject​.nlm​.nih.gov/view_hsrproj_record/20191416. Exclusion Code: X7.

461.

Meenan RT, Goodman MJ, Fishman PA, et al. Using risk-adjustment models to identify high-cost risks. Med Care. 2003 Nov;41(11):1301–12. doi: 10.1097/01.Mlr.0000094480.13057.75. PMID: 22264989. Exclusion Code: X1. [PubMed: 14583693] [CrossRef]

462.

Mehl-Madrona LE. Prevalence of psychiatric diagnoses among frequent users of rural emergency medical services. Can J Rural Med. 2008 Winter;13(1):22–30. PMID: 18727695. Exclusion Code: X1. [PubMed: 18208649]

463.

Melanie Bella CS, Karen LLanos, Stephen A. Somers. Purchasing Strategies to Improve Care Management for Complex Populations: A National Scan of State Purchasers. Center for Health Care Strategies: Strategies CfHC; 2008. https://www​.chcs.org​/resource/purchasing-strategies-to-improve-care-management-for-complex-populations-a-national-scan-of-state-purchasers/. Exclusion Code: X7.

464.

Meng X, Muggli T, Baetz M, et al. Disordered lives: life circumstances and clinical characteristics of very frequent users of emergency departments for primary mental health complaints. Psychiatry Res. 2017 Jun;252:9–15. doi: 10.1016/j.psychres.2017.02.044. PMID: 27734180. Exclusion Code: X1. [PubMed: 28237761] [CrossRef]

465.

Mercer T, Bae J, Kipnes J, et al. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center. J Hosp Med. 2015;10(7):419–24. doi: 10.1002/jhm.2351. PMID: 109592613. Language: English. Entry Date: 20150923. Revision Date: 20160630. Publication Type: journal article. Journal Subset: Biomedical. Exclusion Code: X1. [PubMed: 25854685] [CrossRef]

466.

Meyers DJ, Belanger E, Joyce N, et al. Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries. JAMA Intern Med. 2019 Apr 1;179(4):524–32. doi: 10.1001/jamainternmed.2018.7639. PMID: 32330140. Exclusion Code: X1. [PMC free article: PMC6450306] [PubMed: 30801625] [CrossRef]

467.

Middleton A, Woodward A, Gunn J, et al. How do frequent users of crisis helplines differ from other users regarding their reasons for calling? Results from a survey with callers to Lifeline, Australia’s national crisis helpline service. Health Soc Care Community. 2017 May;25(3):1041–9. doi: 10.1111/hsc.12404. PMID: 28495031. Exclusion Code: X1. [PubMed: 27862572] [CrossRef]

468.

Miller JB, Brauer E, Rao H, et al. The most frequent ED patients carry insurance and a significant burden of disease. Am J Emerg Med. 2013 Jan;31(1):16–9. doi: 10.1016/j.ajem.2012.05.001. PMID: 23970594. Exclusion Code: X4. [PubMed: 22795986] [CrossRef]

469.

Minassian A, Vilke GM, Wilson MP. Frequent emergency department visits are more prevalent in psychiatric, alcohol abuse, and dual diagnosis conditions than in chronic viral illnesses such as hepatitis and human immunodeficiency virus. J Emerg Med. 2013 Oct;45(4):520–5. doi: 10.1016/j.jemermed.2013.05.007. PMID: 22569944. Exclusion Code: X4. [PubMed: 23845528] [CrossRef]

470.

Mishra S, Gregson M, Lalumiere ML. Framing effects and risk-sensitive decision making. Br J Psychol. 2012 Feb;103(1):83–97. doi: 10.1111/j.2044-8295.2011.02047.x. PMID: 21213152. Exclusion Code: X1. [PubMed: 22229776] [CrossRef]

471.

Mitton CR, Adair CE, McDougall GM, et al. Continuity of care and health care costs among persons with severe mental illness. Psychiatr Serv. 2005 Sep;56(9):1070–6. doi: 10.1176/appi.ps.56.9.1070. PMID: 11508640. Exclusion Code: X1. [PubMed: 16148319] [CrossRef]

472.

Moe J, Bailey AL, Oland R, et al. Defining, quantifying, and characterizing adult frequent users of a suburban Canadian emergency department. Cjem. 2013 Jul;15(4):214–26. PMID: 23337095. Exclusion Code: X1. [PubMed: 23777993]

473.

Moe J, Kirkland SW, Rawe E, et al. Effectiveness of interventions to decrease emergency department visits by adult frequent users: a systematic review. Acad Emerg Med. 2017 Jan;24(1):40–52. doi: 10.1111/acem.13060. PMID: 27473387. Exclusion Code: X1. [PubMed: 27473387] [CrossRef]

474.

Moon S, Shin J. Health care utilization among Medicare-Medicaid dual eligibles: a count data analysis. BMC Public Health. 2006 Apr 5;6:88. doi: 10.1186/1471-2458-6-88. PMID: 16906566. Exclusion Code: X1. [PMC free article: PMC1450274] [PubMed: 16595021] [CrossRef]

475.

Moore DT, Rosenheck RA. Factors Affecting Emergency Department Use by a Chronically Homeless Population. Psychiatr Serv. 2016 Dec 1;67(12):1340–7. doi: 10.1176/appi.ps.201500526. PMID: 27540081. Exclusion Code: X1. [PMC free article: PMC5133170] [PubMed: 27417899] [CrossRef]

476.

Moore G, Gerdtz M, Manias E, et al. Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: implications for service delivery. BMC Public Health. 2007 Nov 10;7:320. doi: 10.1186/1471-2458-7-320. PMID: 18281644. Exclusion Code: X1. [PMC free article: PMC2222161] [PubMed: 17996112] [CrossRef]

477.

Moore M, Conrick KM, Reddy A, et al. From Their Perspective: The Connection between Life Stressors and Health Care Service Use Patterns of Homeless Frequent Users of the Emergency Department. Health Soc Work. 2019 May 1;44(2):113–22. doi: 10.1093/hsw/hlz010. PMID: 32798454. Exclusion Code: X11. [PMC free article: PMC6642452] [PubMed: 30855682] [CrossRef]

478.

Moore TA, Miller AL, Lopez L, et al. High utilizers of inpatient state hospital services. Schizophr Bull. 2009 Mar;35:133-. PMID: WOS:000263964700385. Exclusion Code: X1.

479.

Morgan PA, Smith VA, Berkowitz TSZ, et al. Impact Of Physicians, Nurse Practitioners, And Physician Assistants On Utilization And Costs For Complex Patients. Health Aff (Millwood). 2019 Jun;38(6):1028–36. doi: 10.1377/hlthaff.2019.00014. PMID: 31753736. Exclusion Code: X1. [PubMed: 31158006] [CrossRef]

480.

Morgello S, Gensler G, Sherman S, et al. Frailty in medically complex individuals with chronic HIV. AIDS. 2019 Aug 1;33(10):1603–11. doi: 10.1097/qad.0000000000002250. PMID: 31706604. Exclusion Code: X1. [PMC free article: PMC6760300] [PubMed: 31305330] [CrossRef]

481.

Mortensen K. Access to primary and specialty care and emergency department utilization of medicaid enrollees needing specialty care. J Health Care Poor Underserved. 2014 May;25(2):801–13. doi: 10.1353/hpu.2014.0097. PMID: 24576026. Exclusion Code: X4. [PubMed: 24858887] [CrossRef]

482.

Moschetti K, Iglesias K, Baggio S, et al. Health care costs of case management for frequent users of the emergency department: Hospital and insurance perspectives. PLoS One. 2018;13(9):e0199691. doi: 10.1371/journal.pone.0199691. PMID: 30031403. Exclusion Code: X1. [PMC free article: PMC6152853] [PubMed: 30248102] [CrossRef]

483.

Moses K, Hamblin A, Somers S. Supportive housing for chronically homeless Medicaid enrollees: state strategies. [Hamilton, N.J.]: Center for Health Care Strategies; 2016. Exclusion Code: X1.

484.

Mullangi S, Press MJ, Ryan AM. A delicate balance: Accountability for very high-cost patients in new payment models. Healthcare-the Journal of Delivery Science and Innovation. 2019 Dec;7(4):3. doi: 10.1016/j.hjdsi.2019.100366. PMID: WOS:000500712400001. Exclusion Code: X1. [PubMed: 31558367] [CrossRef]

485.

Murphy SM, Neven D. Cost-effective: emergency department care coordination with a regional hospital information system. J Emerg Med. 2014 Aug;47(2):223–31. doi: 10.1016/j.jemermed.2013.11.073. PMID: 24717708. Exclusion Code: X1. [PubMed: 24508115] [CrossRef]

486.

Murtagh Kurowski E, Byczkowski T, Grupp-Phelan JM. Comparison of emergency care delivered to children and young adults with complex chronic conditions between pediatric and general emergency departments. Acad Emerg Med. 2014 Jul;21(7):778–84. doi: 10.1111/acem.12412. PMID: 23182399. Exclusion Code: X1. [PubMed: 25039935] [CrossRef]

487.

Myers LA, Carlson PN, Krantz PW, et al. Development and Implementation of a Community Paramedicine Program in Rural United States. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health. 2020;21(5):1227–33. doi: 10.5811/westjem.2020.7.44571. PMID: 146108730. Language: English. Entry Date: 20201013. Revision Date: 20201013. Publication Type: Article. Exclusion Code: X1. [PMC free article: PMC7514407] [PubMed: 32970579] [CrossRef]

488.

Naessens JA, Baird MA, Van Houten HK, et al. Predicting persistently high primary care use. Ann Fam Med. 2005 Jul–Aug;3(4):324–30. doi: 10.1370/afm.352. PMID: WOS:000231336100008. Exclusion Code: X1. [PMC free article: PMC1466904] [PubMed: 16046565] [CrossRef]

489.

National Academy for State Health Policy , Urban Institute, RTI International. Financial alignment initiative annual report: Washington health homes MFFS Demonstration Bethesda, MD: Centers for Medicare & Medicaid Services; 2017. https://www​.cms.gov/Medicare-Medicaid-Coordination​/Medicare-and-Medicaid-Coordination​/Medicare-Medicaid-Coordination-Office​/FinancialAlignmentInitiative​/Downloads​/WAFirstAnnualEvalReport.pdf. Exclusion Code: X1.

490.

Nault Connors JD, Binkley BL, Graff JC, et al. How patient experience informed the SafeMed Program: Lessons learned during a Health Care Innovation Award to improve care for super-utilizers. Healthc (Amst). 2019 Mar;7(1):13–21. doi: 10.1016/j.hjdsi.2018.02.002. Exclusion Code: X1. [PubMed: 29477610] [CrossRef]

491.

Navathe A. Spending and outcomes for complex Medicare Advantage patients. University of Pennsylvania. 2016. https:​//clinicaltrials​.gov/ct2/show/NCT02922361. Exclusion Code: X7.

492.

Navathe AS. Segmenting high-need, high-cost veterans into potentially actionable subgroups. Corporal Michael J. Crescenz VA Medical Center, Center for Health Equity Research and Promotion 2018. https://www​.hsrd.research​.va.gov/research/abstracts​.cfm?Project_ID=2141706856. Exclusion Code: X7.

493.

Neighbors CJ, Yerneni R, O’Grady MA, et al. Recurrent use of inpatient withdrawal management services: characteristics, service use, and cost among Medicaid clients. J Subst Abuse Treat. 2018;92:77–84. doi: 10.1016/j.jsat.2018.06.013. Exclusion Code: X1. [PubMed: 30032948] [CrossRef]

494.

Nejtek VA, Aryal S, Talari D, et al. A pilot mobile integrated healthcare program for frequent utilizers of emergency department services. Am J Emerg Med. 2017 Nov;35(11):1702–5. doi: 10.1016/j.ajem.2017.04.061. PMID: 27473387. Exclusion Code: X1. [PubMed: 28495031] [CrossRef]

495.

Nelson RE, Suo Y, Pettey W, et al. Costs Associated with Health Care Services Accessed through VA and in the Community through Medicare for Veterans Experiencing Homelessness. Health Serv Res. 2018 Dec;53 Suppl 3(Suppl Suppl 3):5352–74. doi: 10.1111/1475-6773.13054. PMID: 30246368. Exclusion Code: X1. [PMC free article: PMC6235814] [PubMed: 30246368] [CrossRef]

496.

Nevola A, Morris ME, Felix HC, et al. Improving quality of life assessments for high-need adult Medicaid service users with mental health conditions. Qual Life Res. 2020. doi: 10.1007/s11136-020-02694-0. Exclusion Code: X9. [PubMed: 33211222] [CrossRef]

497.

Ng SHX, Rahman N, Ang IYH, et al. Characterization of high healthcare utilizer groups using administrative data from an electronic medical record database. BMC Health Serv Res. 2019;19(1):452. doi: 10.1186/s12913-019-4239-2. Exclusion Code: X1. [PMC free article: PMC6612067] [PubMed: 31277649] [CrossRef]

498.

Noble N, Paul C, Carey M, et al. A randomised trial assessing the acceptability and effectiveness of providing generic versus tailored feedback about health risks for a high need primary care sample. BMC Fam Pract. 2015 Aug 5;16:95. doi: 10.1186/s12875-015-0309-7. PMID: 26809051. Exclusion Code: X1. [PMC free article: PMC4525725] [PubMed: 26243144] [CrossRef]

499.

Noel K, Messina C, Hou W, et al. Tele-transitions of care (TTOC): a 12-month, randomized controlled trial evaluating the use of Telehealth to achieve triple aim objectives. BMC Fam Pract. 2020 Feb 7;21(1):27. doi: 10.1186/s12875-020-1094-5. PMID: 30855682. Exclusion Code: X5. [PMC free article: PMC7007639] [PubMed: 32033535] [CrossRef]

500.

Nolan RD, Kirkland C, Johnson A, et al. International systematic review on high utilizers diagnosed with severe mental illness. Health Behavior and Policy Review. 2019 Jan;6(1):3–17. doi: 10.14485/hbpr.6.1.1. PMID: WOS:000456577600001. Exclusion Code: X1. [CrossRef]

501.

Norelli LJ, Coates AD, Kovasznay BM. Cancer risk from diagnostic radiology in a deliberate self-harm patient. Acta Psychiatr Scand. 2010 Nov;122(5):427–30. doi: 10.1111/j.1600-0447.2010.01538.x. PMID: 21039327. Exclusion Code: X1. [PubMed: 20136800] [CrossRef]

502.

Norman GJ, Orton K, Wade A, et al. Operation and challenges of home-based medical practices in the US: findings from six aggregated case studies. BMC Health Serv Res. 2018 Jan 27;18(1):45. doi: 10.1186/s12913-018-2855-x. PMID: 30404766. Exclusion Code: X1. [PMC free article: PMC5787297] [PubMed: 29374478] [CrossRef]

503.

Norman GJ, Wade AJ, Morris AM, et al. Home and community-based services coordination for homebound older adults in home-based primary care. BMC Geriatr. 2018 Oct 11;18(1):241. doi: 10.1186/s12877-018-0931-z. PMID: 29630852. Exclusion Code: X1. [PMC free article: PMC6180527] [PubMed: 30305053] [CrossRef]

504.

Nothelle S. Characterization and effect of co-existence of care management programs for high-need, high-cost older adults. Johns Hopkins Medicine, Department of Medicine. 2018. https://hsrproject​.nlm​.nih.gov/view_hsrproj_record/20191491. Exclusion Code: X7.

505.

Novak M, Mucsi I, Shapiro CM, et al. Increased utilization of health services by insomniacs--an epidemiological perspective. J Psychosom Res. 2004 May;56(5):527–36. doi: 10.1016/j.jpsychores.2004.02.007. PMID: 11794737. Exclusion Code: X1. [PubMed: 15172209] [CrossRef]

506.

Nuti SV, Doupe P, Villanueva B, et al. Characterizing subgroups of high-need, high-cost patients based on their clinical conditions: a machine learning-based analysis of Medicaid claims data. J Gen Intern Med. 2019 Aug;34(8):1406–8. doi: 10.1007/s11606-019-04941-8. PMID: 30887432. Exclusion Code: X4. [PMC free article: PMC6667598] [PubMed: 30887432] [CrossRef]

507.

Oderda GM, Gunning K, LaFleur J, et al. Reviews of Utah Medicaid high utilizers to control drug costs. Value Health. 2003 May–Jun;6(3):206-. doi: 10.1016/s1098-3015(10)63869-7. PMID: WOS:000183419000071. Exclusion Code: X1. [CrossRef]

508.

O’Donohue W, Cucciare M. Pathways to Medical utilization. J Clin Psychol Med Settings. 2005;12(2):185–97. doi: 10.1007/s10880-005-3278-5. PMID: 16903251. Exclusion Code: X1. [CrossRef]

509.

O’Donohue W, Cucciare MA. The role of psychological factors in medical presentations. J Clin Psychol Med Settings. 2005 Mar;12(1):13–24. doi: 10.1007/s10880-005-0908-x. PMID: WOS:000226939100002. Exclusion Code: X1. [CrossRef]

510.

Okin RL, Boccellari A, Azocar F, et al. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med. 2000 Sep;18(5):603–8. doi: 10.1053/ajem.2000.9292. PMID: 16383099. Exclusion Code: X1. [PubMed: 10999578] [CrossRef]

511.

Okunogbe A, Meredith LS, Chang ET, et al. Care coordination and provider stress in primary care management of high-risk patients. J Gen Intern Med. 2018 Jan;33(1):65–71. doi: 10.1007/s11606-017-4186-8. PMID: 28971306. Exclusion Code: X1. [PMC free article: PMC5756166] [PubMed: 28971306] [CrossRef]

512.

Okuyemi KS, Frey B. Describing and predicting frequent users of an emergency department. J Assoc Acad Minor Phys. 2001 Mar;12(1–2):119–23. PMID: 11543989. Exclusion Code: X4. [PubMed: 11851196]

513.

O’Leary KJ, Chapman MM, Foster S, et al. Frequently hospitalized patients’ perceptions of factors contributing to high hospital use. J Hosp Med. 2019 Mar 20;14:E1–e6. doi: 10.12788/jhm.3175. PMID: 30897060. Exclusion Code: X1. [PMC free article: PMC6715053] [PubMed: 30897060] [CrossRef]

514.

Olofsson P, Carlstrom ED, Back-Pettersson S. During and beyond the triage encounter: chronically ill elderly patients’ experiences throughout their emergency department attendances. Int Emerg Nurs. 2012 Oct;20(4):207–13. doi: 10.1016/j.ienj.2012.03.006. PMID: 22948324. Exclusion Code: X1. [PubMed: 23084509] [CrossRef]

515.

Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med J. 2001 Nov;18(6):430–4. doi: 10.1136/emj.18.6.430. PMID: 11682580. Exclusion Code: X1. [PMC free article: PMC1725740] [PubMed: 11696488] [CrossRef]

516.

O’Malley AS, Rich EC, Sarwar R, et al. How accountable care organizations use population segmentation to care for high-need, high-cost patients. Commonwealth. 2019. https://www​.commonwealthfund​.org/publications​/issue-briefs/2019​/jan/how-acos-use-segmentation-high-need-high-cost. Exclusion Code: X1. [PubMed: 30645057]

517.

Ondler C, Hegde GG, Carlson JN. Resource utilization and health care charges associated with the most frequent ED users. Am J Emerg Med. 2014 Oct;32(10):1215–9. doi: 10.1016/j.ajem.2014.07.013. PMID: 25342825. Exclusion Code: X4. [PubMed: 25154348] [CrossRef]

518.

Oreskovic NM, Maniates J, Weilburg J, et al. Optimizing the use of electronic health records to identify high-risk psychosocial determinants of health. JMIR Med Inform. 2017 Aug 14;5(3):e25. doi: 10.2196/medinform.8240. PMID: 28807893. Exclusion Code: X1. [PMC free article: PMC5575417] [PubMed: 28807893] [CrossRef]

519.

O’Rielly C, Sutherland L, Wong C. The characteristics and effectiveness of interventions targeting chronic pain patients in the emergency department: A systematic review and meta-analysis. Canadian Journal of Emergency Medicine. 2019;21:S98–S9. doi: 10.1017/cem.2019.288. Exclusion Code: X7. [CrossRef]

520.

Orza M. High hopes: public health approaches to reducing the need for health care. Washington, D.C.: National Health Policy Forum; 2010. Exclusion Code: X1.

521.

Osborn R. Israel-United States meeting on caring for high need/high cost patients 2017. Haifa: Commonwealth Fund; 2016. Exclusion Code: X1.

522.

Ostermeyer B, Baweja NU, Schanzer B, et al. Frequent utilizers of emergency departments: characteristics and intervention opportunities. Psychiat Ann. 2018 Jan;48(1):42–50. doi: 10.3928/00485713-20171206-02. PMID: WOS:000425843600007. Exclusion Code: X1. [CrossRef]

523.

Oxman TE, Dietrich AJ, Williams JW, et al. A three-component model for reengineering systems for the treatment of depression in primary care. Psychosomatics. 2002 Nov–Dec;43(6):441–50. doi: 10.1176/appi.psy.43.6.441. PMID: WOS:000179173900002. Exclusion Code: X1. [PubMed: 12444226] [CrossRef]

524.

Oyffe I, Kurs R, Gelkopf M, et al. Revolving-door patients in a public psychiatric hospital in Israel: cross sectional study. Croat Med J. 2009 Dec;50(6):575–82. doi: 10.3325/cmj.2009.50.575. PMID: 19446122. Exclusion Code: X1. [PMC free article: PMC2802091] [PubMed: 20017226] [CrossRef]

525.

Panopalis P, Gillis JZ, Yazdany J, et al. Frequent use of the emergency department among persons with systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2010 Mar;62(3):401–8. doi: 10.1002/acr.20107. PMID: 19995099. Exclusion Code: X4. [PMC free article: PMC3759153] [PubMed: 20391487] [CrossRef]

526.

Parikh R, Linn K, Yan J, et al. Identifying distinct subgroups of high-need, high-cost veterans using machine learning clustering methods. J Gen Intern Med. 2020;35(SUPPL 1):S155. doi: 10.1007/s11606-020-05890-3. Exclusion Code: X1. [CrossRef]

527.

Park S, Langellier BA, Burke RE, et al. Association of Medicare Advantage Penetration With Per Capita Spending, Emergency Department Visits, and Readmission Rates Among Fee-for-Service Medicare Beneficiaries With High Comorbidity Burden. Med Care Res Rev.10. doi: 10.1177/1077558720952582. PMID: WOS:000563025900001. Exclusion Code: X9. [PubMed: 32842874] [CrossRef]

528.

Parson P. PBS Newshour partnership on high-need high-cost populations. Greater Washington Educational Telecommunications Association: Commonwealth Fund; 2016. Exclusion Code: X7.

529.

Patten SB, Williams JV, Esposito E, et al. Self-reported thyroid disease and mental disorder prevalence in the general population. Gen Hosp Psychiatry. 2006 Nov–Dec;28(6):503–8. doi: 10.1016/j.genhosppsych.2006.09.001. PMID: 16484820. Exclusion Code: X1. [PubMed: 17088166] [CrossRef]

530.

Peck KA. To what extent are chronic care management processes and programs in place to manage patients with high-need, high-cost chronic illnesses? : Commonwealth Fund; 2018. Exclusion Code: X7.

531.

Peddie S, Richardson S, Salt L, et al. Frequent attenders at emergency departments: research regarding the utility of management plans fails to take into account the natural attrition of attendance. N Z Med J. 2011 Mar 25;124(1331):61–6. PMID: 21597126. Exclusion Code: X1. [PubMed: 21725414]

532.

Peng CJ-D. Health services utilization of older adults with depression and comorbid chronic health conditions: evidence from China: ProQuest Information & Learning; 2018. Exclusion Code: X1.

533.

Perez Jolles M, Lengnick-Hall R, Mittman BS. Core functions and forms of complex health interventions: a patient-centered medical home illustration. J Gen Intern Med. 2019;34(6):1032–8. doi: 10.1007/s11606-018-4818-7. Exclusion Code: X1. [PMC free article: PMC6544719] [PubMed: 30623387] [CrossRef]

534.

Petersen LA, Woodard LD, Henderson LM, et al. Will hypertension performance measures used for pay-for-performance programs penalize those who care for medically complex patients? Circulation. 2009 Jun 16;119(23):2978–85. doi: 10.1161/circulationaha.108.836544. PMID: 19083209. Exclusion Code: X1. [PMC free article: PMC2743388] [PubMed: 19487595] [CrossRef]

535.

Peytremann-Bridevaux I, Voellinger R, Santos-Eggimann B. Healthcare and preventive services utilization of elderly Europeans with depressive symptoms. J Affect Disord. 2008 Jan;105(1–3):247–52. doi: 10.1016/j.jad.2007.04.011. PMID: 20001167. Exclusion Code: X1. [PubMed: 17509695] [CrossRef]

536.

Phipps EJ, Singletary SB, Cooblall CA, et al. Food insecurity in patients with high hospital utilization. Popul Health Manag. 2016 Dec;19(6):414–20. doi: 10.1089/pop.2015.0127. PMID: 26141469. Exclusion Code: X1. [PubMed: 27008540] [CrossRef]

537.

Pietz K, Byrne MM, Petersen LA. A decision-theoretic approach to identifying future high-cost patients. Med Care. 2006 Sep;44(9):842–9. doi: 10.1097/01.mlr.0000220680.19667.da. PMID: 16294676. Exclusion Code: X4. [PubMed: 16932136] [CrossRef]

538.

Placona AM, King R, Wang F. Longitudinal Clustering of High-cost Patients’ Spend Trajectories:Delineating Individual Behaviors from Aggregate Trends. AMIA Annu Symp Proc. 2018;2018:907–15. PMID: 29049488. Exclusion Code: X9. [PMC free article: PMC6371335] [PubMed: 30815133]

539.

Pleticha J, Prakken S, Buchheit T, et al. Financial impact of intensive outpatient pain management of duke health system high utilizers. Anesth Analg. 2017 May;124:786–8. PMID: WOS:000412683000408. Exclusion Code: X1.

540.

Polluste K, Kalda R, Lember M. Satisfaction with the access to the health services of the people with chronic conditions in Estonia. Health Policy. 2007 Jun;82(1):51–61. doi: 10.1016/j.healthpol.2006.08.004. PMID: 18030205. Exclusion Code: X1. [PubMed: 17011063] [CrossRef]

541.

Ponka D. The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review. PLoS One. 2020. Exclusion Code: X7. [PMC free article: PMC7313544] [PubMed: 32271769]

542.

Ponka D, Agbata E, Kendall C, et al. The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review. PLoS One. 2020;15(4):e0230896. doi: 10.1371/journal.pone.0230896. PMID: 32271769. Exclusion Code: X7. [PMC free article: PMC7313544] [PubMed: 32271769] [CrossRef]

543.

Poole S, Grannis S, Shah NH. Predicting Emergency Department Visits. AMIA Jt Summits Transl Sci Proc. 2016;2016:438–45. PMID: 27570684. Exclusion Code: X1. [PMC free article: PMC5001776] [PubMed: 27570684]

544.

Pope D, Fernandes CM, Bouthillette F, et al. Frequent users of the emergency department: a program to improve care and reduce visits. CMAJ. 2000 Apr 4;162(7):1017–20. PMID: 15446621. Exclusion Code: X1. [PMC free article: PMC1232308] [PubMed: 10763402]

545.

Poremski D, Harris DW, Kahan D, et al. Improving continuity of care for frequent users of emergency departments: service user and provider perspectives. Gen Hosp Psychiatry. 2016 May–Jun;40:55–9. doi: 10.1016/j.genhosppsych.2016.01.004. PMID: 27206120. Exclusion Code: X1. [PubMed: 26906469] [CrossRef]

546.

Powers A, Strube MJ, Oltmanns TF. Personality pathology and increased use of medical resources in later adulthood. Am J Geriatr Psychiatry. 2014 Dec;22(12):1478–86. doi: 10.1016/j.jagp.2013.10.009. PMID: 23957900. Exclusion Code: X1. [PMC free article: PMC4000746] [PubMed: 24315559] [CrossRef]

547.

Powers M. Sustainable payment models to support effective care management programs for high-need, high-cost patients. Pacific Business Group on Health 2017. https://hsrproject​.nlm​.nih.gov/view_hsrproj_record/20191027. Exclusion Code: X7.

548.

Prados-Torres A, Cura-Gonzalez ID, Prados-Torres JD, et al. MULTIPAP Study: improving healthcare for patients with multimorbidity. Br J Gen Pract. 2020;70. doi: 10.3399/bjgp20X711257. PMID: CN-02142881. Exclusion Code: X6. [PubMed: 32554653] [CrossRef]

549.

Prater L, Sanchez A, Modan G, et al. Electronic Health Record Documentation Patterns of Recorded Primary Care Visits Focused on Complex Communication: A Qualitative Study. Appl Clin Inform. 2019 Mar;10(2):247–53. doi: 10.1055/s-0039-1683986. PMID: 30970382. Exclusion Code: X1. [PMC free article: PMC6458018] [PubMed: 30970382] [CrossRef]

550.

Pruitt Z, Emechebe N, Quast T, et al. Expenditure Reductions Associated with a Social Service Referral Program. Popul Health Manag. 2018 Dec;21(6):469–76. doi: 10.1089/pop.2017.0199. PMID: 29664702. Exclusion Code: X1. [PMC free article: PMC6276598] [PubMed: 29664702] [CrossRef]

551.

Pyne JM, Rost KM, Farahati F, et al. One size fits some: the impact of patient treatment attitudes on the cost-effectiveness of a depression primary-care intervention. Psychol Med. 2005 Jun;35(6):839–54. doi: 10.1017/s0033291704003332. PMID: WOS:000231499900007. Exclusion Code: X1. [PubMed: 15997604] [CrossRef]

552.

Radcliff TA, Côté MJ, Duncan RP. The identification of high-cost patients. Hosp Top. 2005 Summer;83(3):17–24. doi: 10.3200/htps.83.3.17-24. PMID: 15612167. Exclusion Code: X9. [PubMed: 16294676] [CrossRef]

553.

Radley DC, Hayes SL, McCarthy D. Assessing state variation in high-need adult populations and their care experiences. Commonwealth Fund. 2017. https://www​.commonwealthfund​.org/publications​/issue-briefs/2017​/aug/assessing-state-variation-high-need-adult-populations-and-their. Exclusion Code: X1.

554.

Radley DC, Hayes SL, McCarthy D. Percent of high-need adults who went without physician care and prescriptions because of costs varied widely. Commonwealth Fund; 2017. Exclusion Code: X7.

555.

Radley DC, Hayes SL, McCarthy D. High-need adults more likely than adults overall to not see a doctor because of costs, but rates vary. Commonwealth Fund; 2017. Exclusion Code: X7.

556.

Ramage-Morin PL, Gilmour H. Chronic pain at ages 12 to 44. Health Rep. 2010 Dec;21(4):53–61. PMID: 20038842. Exclusion Code: X1. [PubMed: 21269012]

557.

Ramey L, Goldstein R, Zafonte R, et al. Variation in 30-day readmission rates among medically complex patients at inpatient rehabilitation facilities and contributing factors. J Am Med Dir Assoc. 2016 Aug 1;17(8):730–6. doi: 10.1016/j.jamda.2016.03.019. PMID: 26930236. Exclusion Code: X1. [PubMed: 27161849] [CrossRef]

558.

Rapoport R. Surveying high-need, high-cost patients about how they experience health system reform. SSRS. 2016. https://www​.commonwealthfund​.org/grants/surveying-high-need-high-cost-patients-about-how-they-experience-health-system-reform. Exclusion Code: X7.

559.

Raven MC. Homelessness and the Practice of Emergency Medicine: Challenges, Gaps in Care, and Moral Obligations. Ann Emerg Med. 2019 Nov;74(5s):S33–s7. doi: 10.1016/j.annemergmed.2019.08.440. PMID: 31655672. Exclusion Code: X9. [PubMed: 31655672] [CrossRef]

560.

Raven MC, Doran KM, Kostrowski S, et al. An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study. BMC Health Serv Res. 2011 Oct 13;11:270. doi: 10.1186/1472-6963-11-270. PMID: 21995329. Exclusion Code: X1. [PMC free article: PMC3212942] [PubMed: 21995329] [CrossRef]

561.

Raven MC, Kotchko SM, Gould DA. Can targeted messaging encourage PCP contact before ED visits? Am J Manag Care. 2013 Jan;19(1):41–5. PMID: 23222127. Exclusion Code: X1. [PubMed: 23379743]

562.

Realmuto L, Walker EA, Weiss L. Struggling to stay on track: participants share benefits and barriers to completing the National Diabetes Prevention Program. New York, NY: New York Academy of Medicine; 2017. Exclusion Code: X1.

563.

. Detecting earlier indicators of homelessness in the free text of medical records. 2014. 2665: 202. Exclusion Code: X1. [PubMed: 25000039]

564.

Reddy A. Understanding the impact of health information exchange-enabled care plans to coordinate care among high-need, high-cost patients. University of Washington, School of Medicine, Department of Medicine, Division of General Internal Medicine. Seattle, Washington: 2018. https://app​.dimensions​.ai/details/grant/grant.7825128. Exclusion Code: X1.

565.

Regenstein M, Andres E. Reducing hospital readmissions among Medicaid patients: a review of the literature. Qual Manag Health Care. 2014;23(1):20–42. doi: 10.1097/QMH.0000000000000016. PMID: 107883398. Language: English. Entry Date: 20140131. Revision Date: 20150712. Publication Type: Journal Article. Exclusion Code: X1. [PubMed: 24368719] [CrossRef]

566.

Rennemark M, Holst G, Fagerstrom C, et al. Factors related to frequent usage of the primary healthcare services in old age: findings from The Swedish National Study on Aging and Care. Health Soc Care Community. 2009 May;17(3):301–11. doi: 10.1111/j.1365-2524.2008.00829.x. PMID: 19098256. Exclusion Code: X1. [PubMed: 19207603] [CrossRef]

567.

Reschovsky JD, Hadley J, Saiontz-Martinez CB, et al. Following the money: factors associated with the cost of treating high-cost Medicare beneficiaries. Health Serv Res. 2011 Aug;46(4):997–1021. doi: 10.1111/j.1475-6773.2011.01242.x. PMID: 27547951. Exclusion Code: X9. [PMC free article: PMC3165175] [PubMed: 21306368] [CrossRef]

568.

Rivlin AM, Burke SP. Preserving the bipartisan commitment to health care delivery system reform. Commonwealth Fund; 2017. Exclusion Code: X7.

569.

Robst J. Developing Models to Predict Persistent High-Cost Cases in Florida Medicaid. Popul Health Manag. 2015 Dec;18(6):467–76. doi: 10.1089/pop.2014.0174. PMID: 28430557. Exclusion Code: X1. [PubMed: 26102363] [CrossRef]

570.

Rochlin DH, Lee CM, Scheuter C, et al. Health Care Is Failing the Most Vulnerable Patients: Three Underused Solutions. Public Health Rep. 2020 Nov;135(6):711–6. doi: 10.1177/0033354920954496. PMID: WOS:000572772800001. Exclusion Code: X1. [PMC free article: PMC7649988] [PubMed: 32962512] [CrossRef]

571.

Rodríguez-Queraltó O, Formiga F, López-Palop R, et al. FRAIL Scale also Predicts Long-Term Outcomes in Older Patients With Acute Coronary Syndromes. J Am Med Dir Assoc. 2020;21(5):683–7.e1. doi: 10.1016/j.jamda.2019.10.007. Exclusion Code: X6. [PubMed: 31780414] [CrossRef]

572.

Rohrer JE, Takahashi PY, Adamson SC. Age, obesity, and medical visits in family medicine. Popul Health Manag. 2008 Oct;11(5):255–9. doi: 10.1089/pop.2008.0005. PMID: 17269846. Exclusion Code: X1. [PubMed: 18942917] [CrossRef]

573.

Rollman BL, Belnap BH, Reynolds CF, et al. A contemporary protocol to assist primary care physicians in the treatment of panic and generalized anxiety disorders. Gen Hosp Psychiatry. 2003 Mar–Apr;25(2):74–82. doi: 10.1016/s0163-8343(03)00004-5. PMID: WOS:000182046600002. Exclusion Code: X1. [PubMed: 12676419] [CrossRef]

574.

Romaire M, Alterbaum R, Collins A. Medicaid behavioral health homes: Lessons learned and early findings from Maine. Psychiatr Serv. 2020;71(11):1179–87. doi: 10.1176/appi.ps.201900490. PMID: 2020-99636-014. Exclusion Code: X1. [PubMed: 32933410] [CrossRef]

575.

Rosen CS. Telephone case monitoring for veterans with PTSD (post-traumatic stress disorder) VA Palo Alto Health Care System, Palo Alto Division. Palo Alto, California: 2006. https://www​.hsrd.research​.va.gov/research/abstracts​.cfm?Project_ID=2141695811. Exclusion Code: X1.

576.

Rosenberg HJ, Rosenberg SD, Wolford Ii GL, et al. The relationship between trauma, PTSD, and medical utilization in three high risk medical populations. Int J Psychiatry Med. 2000;30(3):247–59. doi: 10.2190/J8M8-YDTE-46CB-GYDK. Exclusion Code: X1. [PubMed: 11209992] [CrossRef]

577.

Rosenberg MA, Farrell PM. Predictive modeling of costs for a chronic disease with acute high-cost episodes. North American Actuarial Journal. 2008;12(1):1–19. doi: 10.1080/10920277.2008.10597497. Exclusion Code: X1. [CrossRef]

578.

Rost K, Pyne JM, Dickinson LM, et al. Cost-effectiveness of enhancing primary care depression management on an ongoing basis. Ann Fam Med. 2005 Jan–Feb;3(1):7–14. doi: 10.1370/afm.256. PMID: WOS:000226922000003. Exclusion Code: X1. [PMC free article: PMC1350977] [PubMed: 15671185] [CrossRef]

579.

Rotenberg J, Kinosian B, Boling P, et al. Home-based primary care: beyond extension of the independence at home demonstration. J Am Geriatr Soc. 2018 Apr;66(4):812–7. doi: 10.1111/jgs.15314. PMID: 28468524. Exclusion Code: X4. [PubMed: 29473945] [CrossRef]

580.

Roudsari B, Caetano R, Field C. Alcohol intoxication/dependence, ethnicity and utilisation of health care resources in a level I trauma center. Injury. 2011 Jan;42(1):66–71. doi: 10.1016/j.injury.2010.01.097. PMID: 21199163. Exclusion Code: X1. [PMC free article: PMC2964390] [PubMed: 20106475] [CrossRef]

581.

Rowe JM, Rizzo VM, Kang SY, et al. Time Contribution of Social Workers in Care Management: Value for Older Adults. Prof Case Manag. 2019 Nov/Dec;24(6):306–16. doi: 10.1097/ncm.0000000000000305. PMID: 31580298. Exclusion Code: X1. [PubMed: 31580298] [CrossRef]

582.

Roy-Byrne PP, Wagner AW, Schraufnagel TJ. Understanding and treating panic disorder in the primary care setting. J Clin Psychiatry. 2005;66:16–22. PMID: WOS:000228902800003. Exclusion Code: X1. [PubMed: 15842183]

583.

Rudin RS, Schneider EC, Predmore Z, et al. Knowledge gaps inhibit health IT development for coordinating complex patients’ care. Am J Manag Care. 2016 Sep 1;22(9):e317–22. Exclusion Code: X1. [PubMed: 27662395]

584.

Ruiz S, Snyder LP, Rotondo C, et al. Innovative Home Visit Models Associated With Reductions In Costs, Hospitalizations, And Emergency Department Use. Health Aff (Millwood). 2017 Mar 1;36(3):425–32. doi: 10.1377/hlthaff.2016.1305. PMID: 28264943. Exclusion Code: X1. [PubMed: 28264943] [CrossRef]

585.

Rutgers Biomedical and Health Sciences (RBHS) Working Group on Medicaid High Utilizers. Analysis and recommendations for Medicaid high utilizers in New Jersey. Hotspot Blog. Camden, NJ: Camden Coalition; 2016. Exclusion Code: X1.

586.

Ryan J, Abrams MK, Doty MM, et al. How high-need patients experience health care in the United States. Findings from the 2016 Commonwealth Fund Survey of High-Need Patients. Issue Brief (Commonw Fund). 2016 Dec;43:1–20. PMID: 29118179. Exclusion Code: X1. [PubMed: 27959480]

587.

Ryan J, Brown M. Listening to those living with chronic conditions. Commonwealth Fund; 2016. Exclusion Code: X7.

588.

Sadarangani T, Missaelides L, Eilertsen E, et al. A Mixed-Methods Evaluation of a Nurse-Led Community-Based Health Home for Ethnically Diverse Older Adults With Multimorbidity in the Adult Day Health Setting. Policy Polit Nurs Pract. 2019 Aug;20(3):131–44. doi: 10.1177/1527154419864301. PMID: 30614105. Exclusion Code: X1. [PMC free article: PMC6827350] [PubMed: 31373878] [CrossRef]

589.

Sadowski LS, Kee RA, VanderWeele TJ, et al. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009 May 6;301(17):1771–8. doi: 10.1001/jama.2009.561. PMID: 19295391. Exclusion Code: X1. [PubMed: 19417194] [CrossRef]

590.

Salhi BA, White MH, Pitts SR, et al. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med. 2018 May;25(5):577–93. doi: 10.1111/acem.13358. PMID: 29223132. Exclusion Code: X7. [PubMed: 29223132] [CrossRef]

591.

Salzberg CA, Hayes SL, McCarthy D, et al. Health system performance for the high-need patient: a look at access to care and patient care experiences. Issue Brief (Commonw Fund). 2016 Aug;27:1–12. PMID: 27033015. Exclusion Code: X1. [PubMed: 27571600]

592.

Sambamoorthi U, Walkup J, Olfson M, et al. Antidepressant treatment and health services utilization among HIV-infected Medicaid patients diagnosed with depression. J Gen Intern Med. 2000 May;15(5):311–20. doi: 10.1046/j.1525-1497.2000.06219.x. PMID: WOS:000087185700005. Exclusion Code: X1. [PMC free article: PMC1495453] [PubMed: 10840266] [CrossRef]

593.

Sander LD, Albert M, Okeke N, et al. Building a Medicaid ambulatory complex care program within an urban medical home. Popul Health Manag. 2018 Dec;21(6):446–53. doi: 10.1089/pop.2017.0200. PMID: 29939889. Exclusion Code: X1. [PubMed: 29620961] [CrossRef]

594.

Sanders J, Guse C, Onuoha BC. Pilot study of a new model for managing hypertension in an uninsured population. J Prim Care Community Health. 2013 Jan;4(1):44–9. doi: 10.1177/2150131912451742. PMID: 22511403. Exclusion Code: X1. [PubMed: 23799689] [CrossRef]

595.

Sarabia-Cobo C, Fernandez-Pena R, Taltavull JM, et al. Comparison between attention and experiences of chronic complex patients: A multicentric study. Health Soc Care Community.12. doi: 10.1111/hsc.13269. PMID: WOS:000607935400001. Exclusion Code: X6. [PubMed: 33453131] [CrossRef]

596.

Sarabia-Cobo C, Taltavull-Aparicio JM, Miguélez-Chamorro A, et al. Experiences of caregiving and quality of healthcare among caregivers of patients with complex chronic processes: A qualitative study. Appl Nurs Res. 2020;56:N.PAG-N.PAG. doi: 10.1016/j.apnr.2020.151344. PMID: 147365277. Language: English. Entry Date: 20201209. Revision Date: 20201220. Publication Type: Article. Exclusion Code: X9. [PubMed: 32907769] [CrossRef]

597.

Sarah B. Hunter MH, Brian Briscombe, Matthew Cefalu. Evaluation of Housing for Health Permanent Supportive Housing Program. RAND Corporation 2017. Exclusion Code: X1.

598.

Sarnak DO, Ryan J. How high-need patients experiences the health care system in nine countries. Issue Brief (Commonw Fund). 2016 Jan;1:1–14. PMID: 27595372. Exclusion Code: X1. [PubMed: 26809154]

599.

Sarvepalli S, Parikh MP, Sarvepalli S, et al. High utilizers of inpatient services in patients with esophageal stenosis. Am J Gastroenterol. 2018 Oct;113:S198–S9. PMID: WOS:000464611000346. Exclusion Code: X1.

600.

Saxon L ER, Sobhani M. Health impacts of unlimited access to networked transportation in older adults. The Journal of mHealth. 2019. Exclusion Code: X11.

601.

Schaeffer C, Teter C, Finch EA, et al. A pragmatic randomized comparative effectiveness trial of transitional care for a socioeconomically diverse population: design, rationale and baseline characteristics. Contemp Clin Trials. 2018 Feb;65:53–60. doi: 10.1016/j.cct.2017.12.003. PMID: 28793785. Exclusion Code: X1. [PubMed: 29233720] [CrossRef]

602.

Schaink AK, Kuluski K, Lyons RF, et al. A scoping review and thematic classification of patient complexity: offering a unifying framework. J Comorb. 2012;2:1–9. doi: 10.15256/joc.2012.2.15. PMID: 29090137. Exclusion Code: X1. [PMC free article: PMC5556402] [PubMed: 29090137] [CrossRef]

603.

Schoen C, Solís-Román C, Huober N, et al. On Medicare but at risk: a state-level analysis of beneficiaries who are underinsured or facing high total cost burden. New York: Commonwealth Fund; 2016. Exclusion Code: X1. [PubMed: 27214925]

604.

Schulman M, Thomas-Henkel. Opportunities for complex care programs to address the social determinants of health. Center for Health Care Strategies. 2019. https://www​.chcs.org​/media/TCC-SDOH-022119.pdf. Exclusion Code: X1.

605.

Seferian EG, Afessa B. Demographic and clinical variation of adult intensive care unit utilization from a geographically defined population. Crit Care Med. 2006 Aug;34(8):2113–9. doi: 10.1097/01.Ccm.0000227652.08185.A4. PMID: 16508721. Exclusion Code: X1. [PubMed: 16763514] [CrossRef]

606.

Sewitch MJ, Blais R, Rahme E, et al. Receiving guideline-concordant pharmacotherapy for major depression: Impact on ambulatory and inpatient health service use. Canadian Journal of Psychiatry-Revue Canadienne De Psychiatrie. 2007 Mar;52(3):191–200. doi: 10.1177/070674370705200311. PMID: WOS:000245227900011. Exclusion Code: X1. [PubMed: 17479528] [CrossRef]

607.

Shah T, Brown M, Reed B, et al. High-need patients in their own words. Commonwealth Fund. 2017. https://www​.commonwealthfund​.org/blog/2017​/high-need-patients-their-own-words. Exclusion Code: X1.

608.

Shah T, Brown M, Reed B, et al. Personas for people with three or more chronic conditions. 2019. https://www​.commonwealthfund​.org/publications​/2019/jan/personas-people-three-or-more-chronic-conditions. Exclusion Code: X1.

609.

Shah T, Lewis C, Tsega M, et al. Quick reference guide to promising care models for patients with complex needs. Commonwealth Fund. 2019. https://www​.commonwealthfund​.org/publications​/2019/feb/care-models-patients-complex-needs. Exclusion Code: X1.

610.

Shah V, Stokes J, Sutton M. Effects of non-medical health coaching on multimorbid patients in primary care: a difference-in-differences analysis. BMC Health Serv Res. 2019;19(1):N.PAG-N.PAG. doi: 10.1186/s12913-019-4367-8. PMID: 138199334. Language: English. Entry Date: In Process. Revision Date: 20191220. Publication Type: journal article. Journal Subset: Biomedical. Exclusion Code: X1. [PMC free article: PMC6704561] [PubMed: 31438937] [CrossRef]

611.

Shannon GR, Wilber KH, Allen D. Reductions in costly healthcare service utilization: findings from the Care Advocate Program. J Am Geriatr Soc. 2006 Jul;54(7):1102–7. doi: 10.1111/j.1532-5415.2006.00799.x. PMID: 16866682. Exclusion Code: X1. [PubMed: 16866682] [CrossRef]

612.

Sharpe M, Burton C, Sawhney A, et al. Is co-morbid depression adequately treated in patients repeatedly referred to specialist medical services with symptoms of a medical condition? J Psychosom Res. 2012 Jun;72(6):419–21. doi: 10.1016/j.jpsychores.2012.03.005. PMID: WOS:000305440700002. Exclusion Code: X1. [PubMed: 22656436] [CrossRef]

613.

Sheehan B, Bass C, Briggs R, et al. Somatization among older primary care attenders. Psychol Med. 2003 Jul;33(5):867–77. doi: 10.1017/s003329170300789x. PMID: WOS:000184362600012. Exclusion Code: X1. [PubMed: 12877401] [CrossRef]

614.

Sheff A, Park ER, Neagle M, et al. The patient perspective: utilizing focus groups to inform care coordination for high-risk medicaid populations. BMC Res Notes. 2017 Jul 25;10(1):315. doi: 10.1186/s13104-017-2638-1. PMID: 28743288. Exclusion Code: X1. [PMC free article: PMC5526300] [PubMed: 28743288] [CrossRef]

615.

Shih SL, Gerrard P, Goldstein R, et al. Functional status outperforms comorbidities in predicting acute care readmissions in medically complex patients. J Gen Intern Med. 2015 Nov;30(11):1688–95. doi: 10.1007/s11606-015-3350-2. PMID: 26841193. Exclusion Code: X1. [PMC free article: PMC4617914] [PubMed: 25956826] [CrossRef]

616.

Shim J, Perry B. A social network analysis of poverty and health care utilization. University of California, San Francisco, School of Nursing San Franciso, California: 2018. https://www​.nsf.gov/awardsearch​/showAward?AWD_ID​=1756099&HistoricalAwards=false. Exclusion Code: X1.

617.

Shippee ND, Shah ND, May CR, et al. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol. 2012 Oct;65(10):1041–51. doi: 10.1016/j.jclinepi.2012.05.005. PMID: 22910536. Exclusion Code: X1. [PubMed: 22910536] [CrossRef]

618.

Shortell S. How physician organizations manage care for high-need, high-cost patients. Commonwealth Fund; 2015. Exclusion Code: X1.

619.

Shubeck SP, Thumma JR, Dimick JB, et al. Hot Spotting as a Strategy to Identify High-Cost Surgical Populations. Ann Surg. 2019 Mar;269(3):453–8. doi: 10.1097/sla.0000000000002663. PMID: 31521444. Exclusion Code: X1. [PubMed: 29342019] [CrossRef]

620.

Simmons MM, Gabrielian S, Byrne T, et al. A Hybrid III stepped wedge cluster randomized trial testing an implementation strategy to facilitate the use of an evidence-based practice in VA Homeless Primary Care Treatment Programs. Implement Sci. 2017 Apr 4;12(1):46. doi: 10.1186/s13012-017-0563-2. PMID: 28376839. Exclusion Code: X9. [PMC free article: PMC5379611] [PubMed: 28376839] [CrossRef]

621.

Simon GE, Khandker RK, Ichikawa L, et al. Recovery from depression predicts lower health services costs. J Clin Psychiatry. 2006 Aug;67(8):1226–31. doi: 10.4088/JCP.v67n0808. PMID: WOS:000240252400008. Exclusion Code: X1. [PubMed: 16965200] [CrossRef]

622.

Simon GE, Manning WG, Katzelnick DJ, et al. Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. Arch Gen Psychiatry. 2001;58(2):181–7. doi: 10.1001/archpsyc.58.2.181. PMID: 2001-03074-009. Exclusion Code: X1. [PubMed: 11177120] [CrossRef]

623.

Simpson GG, Hahn HR, Powel AA, et al. A patient-centered emergency department management strategy for sickle-cell disease super-utilizers. West J Emerg Med. 2017 Apr;18(3):335–9. doi: 10.5811/westjem.2016.11.32273. PMID: 27364978. Exclusion Code: X4. [PMC free article: PMC5391880] [PubMed: 28435481] [CrossRef]

624.

Sinaiko A, Meyers D, Rosenthal MB. Review of medical homes shows reduction in spending for high-risk patients, but design and implementation matter. Commonwealth Fund; 2017. Exclusion Code: X7.

625.

Sisco-Taylor B, Fagerlin A, Weir P, et al. THE IMPACT OF AN INTENSIVE OUTPATIENT CLINIC ON MEDICALLY-COMPLEX PATIENTS’ DECISION MAKING OUTCOMES. Med Decis Making. 2020 Jan;40(1):E153–E. PMID: WOS:000509275600134. Exclusion Code: X9.

626.

Siu HY, Steward N, Peter J, et al. A novel primary-specialist care collaborative demonstration project to improve the access and health care of medically complex patients. Chronic Illn. 2017 Sep;13(3):151–70. doi: 10.1177/1742395316674541. PMID: 28683743. Exclusion Code: X1. [PubMed: 28783974] [CrossRef]

627.

Smeets RGM, Elissen AMJ, Kroese M, et al. Identifying subgroups of high-need, high-cost, chronically ill patients in primary care: A latent class analysis. PLoS One. 2020;15(1):e0228103. doi: 10.1371/journal.pone.0228103. PMID: 30931827. Exclusion Code: X6. [PMC free article: PMC6988945] [PubMed: 31995630] [CrossRef]

628.

Smith BJ, McCall TC, Slaven EM, et al. PAs are a solution to the growing need for clinicians to treat an aging population. Jaapa. 2019 Dec;32(12):46–9. doi: 10.1097/01.Jaa.0000604864.79443.79. PMID: 32391756. Exclusion Code: X1. [PubMed: 31770305] [CrossRef]

629.

Smith GM, Cenzer IS, Covinsky K, et al. Who Becomes a High Utilizer? A Case-Control Study of Older Adults in the USA. JGIM: Journal of General Internal Medicine. 2020;35(2):596–8. doi: 10.1007/s11606-019-05331-w. PMID: 141726521. Exclusion Code: X9. [PMC free article: PMC7018874] [PubMed: 31768905] [CrossRef]

630.

Smith KJ, Handler SM, Kapoor WN, et al. Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors. Am J Med Qual. 2016 Jul;31(4):315–22. doi: 10.1177/1062860615574327. PMID: 26472939. Exclusion Code: X1. [PMC free article: PMC4950978] [PubMed: 25753453] [CrossRef]

631.

Smith KW, Bir A, Freeman NL, et al. Impact Of Health Care Delivery System Innovations On Total Cost Of Care. Health Aff (Millwood). 2017 Mar 1;36(3):509–15. doi: 10.1377/hlthaff.2016.1308. PMID: 28264953. Exclusion Code: X11. [PubMed: 28264953] [CrossRef]

632.

Smith MA, Vaughan-Sarrazin MS, Yu M, et al. The importance of health insurance claims data in creating learning health systems: evaluating care for high-need high-cost patients using the National Patient-Centered Clinical Research Network (PCORNet). J Am Med Inform Assoc. 2019 Nov 1;26(11):1305–13. doi: 10.1093/jamia/ocz097. PMID: 32348251. Exclusion Code: X1. [PMC free article: PMC7647219] [PubMed: 31233126] [CrossRef]

633.

Smith RC, Gardiner JC, Armatti S, et al. Screening for high utilizing somatizing patients using a prediction rule derived from the management information system of an HMO: a preliminary study. Med Care. 2001 Sep;39(9):968–78. doi: 10.1097/00005650-200109000-00007. PMID: 15788554. Exclusion Code: X4. [PubMed: 11502954] [CrossRef]

634.

Smith RC, Lein C, Collins C, et al. Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med. 2003 Jun;18(6):478–89. doi: 10.1046/j.1525-1497.2003.20815.x. PMID: WOS:000183796100010. Exclusion Code: X1. [PMC free article: PMC1494880] [PubMed: 12823656] [CrossRef]

635.

Smith TE, Appel A, Donahue SA, et al. Determining engagement in services for high-need individuals with serious mental illness. Adm Policy Ment Health. 2014 Sep;41(5):588–97. doi: 10.1007/s10488-013-0497-1. PMID: 24473411. Exclusion Code: X1. [PMC free article: PMC5361220] [PubMed: 23636712] [CrossRef]

636.

Smith TP, Kennedy SL, Smith M, et al. Physiological improvements and health benefits during an exercise-based comprehensive rehabilitation program in medically complex patients. Exerc Immunol Rev. 2006;12:86–96. PMID: 17576592. Exclusion Code: X1. [PubMed: 17201074]

637.

Smith WR, Poses RM, McClish DK, et al. Prognostic judgments and triage decisions for patients with acute congestive heart failure. Chest. 2002 May;121(5):1610–7. doi: 10.1378/chest.121.5.1610. PMID: 12096148. Exclusion Code: X1. [PubMed: 12006451] [CrossRef]

638.

Smith WR, Sop D, Johnson S, et al. Responsivity of utilization rates to the intensity of case management over time among high-utilizing adults with sickle cell disease. Blood. 2019;134. doi: 10.1182/blood-2019-128259. PMID: CN-02052008. Exclusion Code: X1. [CrossRef]

639.

Smits F, Brouwer HJ, van Weert HCP, et al. Predictability of persistent frequent attendance: a historic 3-year cohort study. Br J Gen Pract. 2009 Feb;59(559):114–9. doi: 10.3399/bjgp09X395120. PMID: WOS:000263896400010. Exclusion Code: X4. [PMC free article: PMC2629841] [PubMed: 19192367] [CrossRef]

640.

Smits FT, Brouwer HJ, Zwinderman AH, et al. Morbidity and doctor characteristics only partly explain the substantial healthcare expenditures of frequent attenders: a record linkage study between patient data and reimbursements data. BMC Fam Pract. 2013;14. doi: 10.1186/1471-2296-14-138. Exclusion Code: X1. [PMC free article: PMC3851974] [PubMed: 24044374] [CrossRef]

641.

Smits FT, Brouwer HJ, Zwinderman AH, et al. Predictability of persistent frequent attendance in primary care: a temporal and geographical validation study. PLoS One. 2013 Sep;8(9). doi: 10.1371/journal.pone.0073125. PMID: WOS:000324481600054. Exclusion Code: X1. [PMC free article: PMC3764153] [PubMed: 24039870] [CrossRef]

642.

Smits FTM, Brouwer HJ, ter Riet G, et al. Epidemiology of frequent attenders: a 3-year historic cohort study comparing attendance, morbidity and prescriptions of one-year and persistent frequent attenders. BMC Public Health. 2009 Jan;9. doi: 10.1186/1471-2458-9-36. PMID: WOS:000264288300001. Exclusion Code: X1. [PMC free article: PMC2649070] [PubMed: 19166622] [CrossRef]

643.

Smits FTM, Mohrs JJ, Beem EE, et al. Defining frequent attendance in general practice. BMC Fam Pract. 2008 Apr;9. doi: 10.1186/1471-2296-9-21. PMID: WOS:000255711400001. Exclusion Code: X1. [PMC free article: PMC2373296] [PubMed: 18412954] [CrossRef]

644.

Smits FTM, Wittkampf KA, Schene AH, et al. Interventions on frequent attenders in primary care. Scand J Prim Health Care. 2008;26(2):111–6. doi: 10.1080/02813430802112997. PMID: WOS:000257081400010. Exclusion Code: X1. [PMC free article: PMC3406646] [PubMed: 18570010] [CrossRef]

645.

So C, Lage DE, Slocum CS, et al. Utility of functional metrics assessed during acute care on hospital outcomes: a systematic review. PM & R : the journal of injury, function, and rehabilitation. 2019;11(5):522–32. doi: 10.1002/pmrj.12013. Exclusion Code: X1. [PMC free article: PMC10108704] [PubMed: 30758920] [CrossRef]

646.

Somers SA, Hamblin A, Verdier JM, et al. Covering low-income childless adults in Medicaid: experiences from selected states. Hamilton, N.J.: Center for Health Care Strategies, Inc.; 2010. Exclusion Code: X1.

647.

Soril LJ, Leggett LE, Lorenzetti DL, et al. Reducing frequent visits to the emergency department: a systematic review of interventions. PLoS One. 2015;10(4):e0123660. doi: 10.1371/journal.pone.0123660. PMID: 25874866. Exclusion Code: X1. [PMC free article: PMC4395429] [PubMed: 25874866] [CrossRef]

648.

Sovso MB, Klojgaard TA, Hansen PA, et al. Repeated ambulance use is associated with chronic diseases - a population-based historic cohort study of patients’ symptoms and diagnoses. Scand J Trauma Resusc Emerg Med. 2019 Apr 16;27(1):46. doi: 10.1186/s13049-019-0624-4. PMID: 30248102. Exclusion Code: X1. [PMC free article: PMC6469091] [PubMed: 30992042] [CrossRef]

649.

Sparling A. Evaluation of a Personalized Care Management Program for High Hospital Utilizers. Atrium Health. Charlotte, NC: January 27, 2021 2021. Exclusion Code: X9.

650.

Springer AM, Condon JR, Li SQ, et al. Frequent use of hospital inpatient services during a nine year period: a retrospective cohort study. BMC Health Serv Res. 2017 May 12;17(1):348. doi: 10.1186/s12913-017-2285-1. PMID: 28376886. Exclusion Code: X1. [PMC free article: PMC5427599] [PubMed: 28499388] [CrossRef]

651.

Sriram V, Wiklund LO, Klein A, et al. Understanding variation in hospitalization trajectory among high cost, high need patients en-rolled in the comprehensive care physician (CCP) program. J Gen Intern Med. 2019;34(2):S393–S4. doi: 10.1007/11606.1525-1497. PMID: CN-01980309. Exclusion Code: X1. [CrossRef]

652.

Stahl JE, Dossett ML, LaJoie AS, et al. Relaxation response and resiliency training and its effect on healthcare resource utilization. PLoS One. 2015;10(10):e0140212. doi: 10.1371/journal.pone.0140212. PMID: 25857588. Exclusion Code: X1. [PMC free article: PMC4603901] [PubMed: 26461184] [CrossRef]

653.

Stark P. Advancing Complex Case Management Competencies in a Health Care System. Prof Case Manag. 2020 Jan/Feb;25(1):19–25. doi: 10.1097/ncm.0000000000000361. PMID: 31157584. Exclusion Code: X2. [PubMed: 31764712] [CrossRef]

654.

Stefanescu Schmidt AC, DeFaria Yeh D, Tabtabai S, et al. National trends in hospitalizations of adults with tetralogy of fallot. Am J Cardiol. 2016 Sep 15;118(6):906–11. doi: 10.1016/j.amjcard.2016.06.034. PMID: 27501487. Exclusion Code: X1. [PMC free article: PMC5349299] [PubMed: 27530825] [CrossRef]

655.

Stergiopoulos V, Gozdzik A, Cohen A, et al. The effect of brief case management on emergency department use of frequent users in mental health: findings of a randomized controlled trial. PLoS One. 2017;12(8):e0182157. doi: 10.1371/journal.pone.0182157. PMID: 26287805. Exclusion Code: X1. [PMC free article: PMC5542632] [PubMed: 28771524] [CrossRef]

656.

Stergiopoulos V, Gozdzik A, Tan de Bibiana J, et al. Brief case management versus usual care for frequent users of emergency departments: the Coordinated Access to Care from Hospital Emergency Departments (CATCH-ED) randomized controlled trial. BMC Health Serv Res. 2016 Aug 24;16(1):432. doi: 10.1186/s12913-016-1666-1. PMID: 26984994. Exclusion Code: X1. [PMC free article: PMC4997752] [PubMed: 27557705] [CrossRef]

657.

Sterk CE, Theall KP, Elifson KW. Health care utilization among drug-using and non-drug-using women. J Urban Health. 2002 Dec;79(4):586–99. doi: 10.1093/jurban/79.4.586. PMID: 12877778. Exclusion Code: X1. [PMC free article: PMC3456726] [PubMed: 12468678] [CrossRef]

658.

Stey AM, Russell MM, Zingmond DS, et al. Using merged clinical and claims registry data to identify high utilizers of surgical inpatient care 1 year after colectomy. J Am Coll Surg. 2015 Aug;221(2):441–51.e1. doi: 10.1016/j.jamcollsurg.2015.03.024. PMID: 27228561. Exclusion Code: X1. [PubMed: 26141469] [CrossRef]

659.

Stirbu I, Kunst AE, Mielck A, et al. Inequalities in utilisation of general practitioner and specialist services in 9 European countries. BMC Health Serv Res. 2011 Oct 31;11:288. doi: 10.1186/1472-6963-11-288. PMID: 21904335. Exclusion Code: X1. [PMC free article: PMC3221557] [PubMed: 22040155] [CrossRef]

660.

Straker JK, Boehle SG, Nelson IM, et al. Common sense for caring organizations: results from a study of high-performing home care agencies and nursing homes. Oxford, Ohio, Columbus, Ohio: Scripps Gerontology Center, Ohio Direct Service Workforce Initiative; 2013. Exclusion Code: X1.

661.

Strategies CfHC. Complex Care Innovation Lab. 2013. https://www​.chcs.org​/project/complex-care-innovation-lab/. Exclusion Code: X2.

662.

Stremikis K, Connors C, Hoo E. Intensive outpatient care program: a care model for the medically complex piloted by employers. Commonwealth Fund. New York, NY: Commonwealth Fund; 2017. Exclusion Code: X1.

663.

Surbhi S, Munshi KD, Bell PC, et al. Drug therapy problems and medication discrepancies during care transitions in super-utilizers. J Am Pharm Assoc (2003). 2016 Nov – Dec;56(6):633–42.e1. doi: 10.1016/j.japh.2016.07.004. PMID: 28863030. Exclusion Code: X1. [PubMed: 27720595] [CrossRef]

664.

Szalda D, Steinway C, Greenberg A, et al. Developing a hospital-wide transition program for young adults with medical complexity. J Adolesc Health. 2019;65(4):476–82. doi: 10.1016/j.jadohealth.2019.04.008. PMID: 2019-37810-001. Exclusion Code: X1. [PubMed: 31277993] [CrossRef]

665.

Tadros AS, Castillo EM, Chan TC, et al. Effects of an emergency medical services-based resource access program on frequent users of health services. Prehosp Emerg Care. 2012 Oct–Dec;16(4):541–7. doi: 10.3109/10903127.2012.689927. PMID: 21161535. Exclusion Code: X1. [PubMed: 22712694] [CrossRef]

666.

Taylor L. Housing and health: an overview of the literature. Health Affairs/RWJF Health Policy Brief Princeton, NJ: 2018. https://www​.healthaffairs​.org/do/10.1377/hpb20180313​.396577/full/. doi: 10.1377/hpb20180313.396577. Exclusion Code: X1. [CrossRef]

667.

Taylor LA, Byhoff E. Money Moves the Mare: The Response of Community-Based Organizations to Health Care’s Embrace of Social Determinants. Milbank Q.38. doi: 10.1111/1468-0009.12491. PMID: WOS:000605768700001. Exclusion Code: X1. [PMC free article: PMC7984660] [PubMed: 33420728] [CrossRef]

668.

Taylor WJ, Reitz AC, Coplin M, et al. Patterns of emergency department high utilizers at grady memorial hospital. Ann Emerg Med. 2017;70(4):S32. Exclusion Code: X4.

669.

Teigland C, Pulungan Z. LEVERAGING DATA-DRIVEN INSIGHTS TO SUPPORT DEVELOPMENT OF TARGETED SUPPLEMENTAL BENEFITS UNDER NEWLY EXPANDED FLEXIBILITIES IN MEDICARE ADVANTAGE TO IMPROVE OUTCOMES IN HIGH-COST, HIGH-NEED BENEFICIARIES. Value Health. 2019 May;22:S302–S. doi: 10.1016/j.jval.2019.04.1456. PMID: WOS:000472670103166. Exclusion Code: X7. [CrossRef]

670.

ten Have M, Vollebergh W, Bijl RV, et al. Predictors of incident care service utilisation for mental health problems in the Dutch general population. Soc Psychiatry Psychiatr Epidemiol. 2001 Mar;36(3):141–9. PMID: 16101645. Exclusion Code: X1. [PubMed: 11465786]

671.

Terra SM. What can claims data tell the case manager? Prof Case Manag. 2008 Jul–Aug;13(4):195–208; quiz 9–10. doi: 10.1097/01.Pcama.0000327408.71354.52. PMID: 18586128. Exclusion Code: X1. [PubMed: 18636003] [CrossRef]

672.

Tewarson H. Improving lives and reducing cost of care for high-need, high-cost Medicaid enrollees with mental illness and substance abuse disorders. National Governors Association, Center for Best Practices 2017. https://hsrproject​.nlm​.nih.gov/view_hsrproj_record/20191099. Exclusion Code: X7.

673.

Thompson T, McQueen A, Croston M, et al. Social Needs and Health-Related Outcomes Among Medicaid Beneficiaries. Health Educ Behav. 2019 Jun;46(3):436–44. doi: 10.1177/1090198118822724. PMID: 30654655. Exclusion Code: X1. [PubMed: 30654655] [CrossRef]

674.

Thornquist L, Biros M, Olander R, et al. Health care utilization of chronic inebriates. Acad Emerg Med. 2002 Apr;9(4):300–8. PMID: 12404942. Exclusion Code: X1. [PubMed: 11927454]

675.

Tompkins R, Khan A. ACHD Care in the United States: Complex Patients, Even More Complex Health Care System. Journal of the American College of Cardiology (JACC). 2020;76(2):183–5. doi: 10.1016/j.jacc.2020.05.030. PMID: 144487246. Language: English. Entry Date: 20200719. Revision Date: 20210110. Publication Type: editorial. Exclusion Code: X1. [PubMed: 32646568] [CrossRef]

676.

Trevena LJ, Simpson JM, Nutbeam D. Soup kitchen consumer perspectives on the quality and frequency of health service interactions. Int J Qual Health Care. 2003 Dec;15(6):495–500. doi: 10.1093/intqhc/mzg065. PMID: 15535509. Exclusion Code: X1. [PubMed: 14660532] [CrossRef]

677.

Trivedi SP, Trawick E, Diuguid-Gerber J, et al. Resource intensive care transitions program impact on 90-day hospital readmissions. J Gen Intern Med. 2019;34(2):S763–. doi: 10.1007/11606.1525-1497. PMID: CN-01981508. Exclusion Code: X5. [CrossRef]

678.

Tsega M, Shah T, Lewis C. The importance of sustainable partnerships for meeting the needs of complex patients: introducing the return-on-investment calculator. Commonwealth Fund. 2019. https://www​.commonwealthfund​.org/blog/2019​/importance-sustainable-partnerships-meeting-needs-complex-patients-introducing-return. Exclusion Code: X1.

679.

Turbow S, Fakunle O, Okosun IS. Multi- and single-year high-utilizers of inpatient services share many clinical and behavioral characteristics. , <Blank>: Springer Nature; 2018. p. 1614–5. Exclusion Code: X1. [PMC free article: PMC6153227] [PubMed: 29948801]

680.

University of New Mexico Health Sciences Center. Leverage innovative care delivery and coordination model: Project ECHO. New Mexico: CMS; 2019. Exclusion Code: X7.

681.

Ustulin M, Woo J, Woo JT, et al. Characteristics of frequent emergency department users with type 2 diabetes mellitus in Korea. J Diabetes Investig. 2018 Mar;9(2):430–7. doi: 10.1111/jdi.12712. PMID: 30055654. Exclusion Code: X1. [PMC free article: PMC5835454] [PubMed: 28686322] [CrossRef]

682.

Valaitis R, Cleghorn L, Ploeg J, et al. Disconnected relationships between primary care and community-based health and social services and system navigation for older adults: a qualitative descriptive study. BMC Fam Pract. 2020 Apr 23;21(1):69. doi: 10.1186/s12875-020-01143-8. PMID: 32326880. Exclusion Code: X6. [PMC free article: PMC7181491] [PubMed: 32326880] [CrossRef]

683.

van den Bussche H, Kaduszkiewicz H, Schafer I, et al. Overutilization of ambulatory medical care in the elderly German population?--An empirical study based on national insurance claims data and a review of foreign studies. BMC Health Serv Res. 2016 Apr 14;16:129. doi: 10.1186/s12913-016-1357-y. PMID: 26841193. Exclusion Code: X1. [PMC free article: PMC4831189] [PubMed: 27074709] [CrossRef]

684.

van der Feltz-Cornelis CM, van Oppen P, Ader HJ, et al. Randomised controlled trial of a collaborative care model with psychiatric consultation for persistent medically unexplained symptoms in general practice. Psychother Psychosom. 2006;75(5):282–9. doi: 10.1159/000093949. PMID: WOS:000239726600003. Exclusion Code: X1. [PubMed: 16899964] [CrossRef]

685.

Van Orden J. Service design for the complex customer: An empirical analysis of mental health integration at Intermountain Healthcare: The University of Utah; 2010. Exclusion Code: X2.

686.

Vanagas G, Klimaviciute-Gudauskiene R. Factors affecting electronic health information needs in primary care patients. Telemed J E Health. 2012 Dec;18(10):724–8. doi: 10.1089/tmj.2012.0031. PMID: 20623250. Exclusion Code: X1. [PubMed: 23095004] [CrossRef]

687.

Vargiu E, Fernandez JM, Gonzales-Gonzales M, et al. A self-management system for complex chronic patients. International Journal of Integrated Care. 2019;19:2. doi: 10.5334/ijic.s3101. PMID: WOS:000493776000102. Exclusion Code: X1. [CrossRef]

688.

Vedsted P, Fink P, Olesen F, et al. Psychological distress as a predictor of frequent attendance in family practice - A cohort study. Psychosomatics. 2001 Sep–Oct;42(5):416–22. doi: 10.1176/appi.psy.42.5.416. PMID: WOS:000171885100007. Exclusion Code: X1. [PubMed: 11739909] [CrossRef]

689.

Veltman-Verhulst SM, van Rijn BB, Westerveld HE, et al. Polycystic ovary syndrome and early-onset preeclampsia: reproductive manifestations of increased cardiovascular risk. Menopause. 2010 Sep–Oct;17(5):990–6. doi: 10.1097/gme.0b013e3181ddf705. PMID: 20508654. Exclusion Code: X1. [PubMed: 20551845] [CrossRef]

690.

Verdier JM, Byrd V, Stone C. Enhanced primary care case management programs in Medicaid: issues and options for states. Hamilton, N.J.: Center for Health Care Strategies, Inc.; 2009. Exclusion Code: X1.

691.

Vest JR, Grannis SJ, Haut DP, et al. Using structured and unstructured data to identify patients’ need for services that address the social determinants of health. Int J Med Inform. 2017 Nov;107:101–6. doi: 10.1016/j.ijmedinf.2017.09.008. PMID: 28930892. Exclusion Code: X1. [PubMed: 29029685] [CrossRef]

692.

Vickers KS, Ridgeway JL, Hathaway JC, et al. Integration of mental health resources in a primary care setting leads to increased provider satisfaction and patient access. Gen Hosp Psychiatry. 2013 Sep–Oct;35(5):461–7. doi: 10.1016/j.genhosppsych.2013.06.011. PMID: WOS:000324473900004. Exclusion Code: X1. [PubMed: 23910217] [CrossRef]

693.

Vickery KD, Bodurtha P, Winkelman TNA, et al. Cross-Sector Service Use Among High Health Care Utilizers In Minnesota After Medicaid Expansion. Health Aff (Millwood). 2018 Jan;37(1):62–9. doi: 10.1377/hlthaff.2017.0991. PMID: 29309230. Exclusion Code: X9. [PubMed: 29309230] [CrossRef]

694.

Vickery KD, Shippee ND, Guzman-Corrales LM, et al. Changes in quality of life among enrollees in Hennepin Health: a Medicaid expansion ACO. Med Care Res Rev. 2020 Feb;77(1):60–73. doi: 10.1177/1077558718769457. PMID: 29749288. Exclusion Code: X1. [PubMed: 29749288] [CrossRef]

695.

Vickery KD, Shippee ND, Menk J, et al. Integrated, Accountable Care For Medicaid Expansion Enrollees: A Comparative Evaluation of Hennepin Health. Med Care Res Rev. 2020;77(1):46–59. doi: 10.1177/1077558718769481. PMID: 140999606. Language: English. Entry Date: 20201020. Revision Date: 20201020. Publication Type: journal article. Exclusion Code: X12. [PubMed: 29749302] [CrossRef]

696.

Viveiros J. Using health care savings to construct supportive housing in New York. In Housing health: innovations in the field Exclusion Code: X1.

697.

Viveiros J. Addressing housing as a health care treatment. Washington, D.C.: Center for Housing Policy; 2015. Exclusion Code: X1.

698.

Vladutiu CJ, Stringer EM, Kandasamy V, et al. Emergency care utilization among pregnant Medicaid recipients in North Carolina: an analysis using linked claims and birth records. Maternal & Child Health Journal. 2019;23(2):265–76. doi: 10.1007/s10995-018-2651-6. PMID: 134855464. Language: English. Entry Date: 20190225. Revision Date: 20190422. Publication Type: Article. Journal Subset: Continental Europe. Exclusion Code: X1. [PubMed: 30600512] [CrossRef]

699.

Von Korff M, Lin EH, Fenton JJ, et al. Frequency and priority of pain patients’ health care use. Clin J Pain. 2007 Jun;23(5):400–8. doi: 10.1097/AJP.0b013e31804ac020. PMID: 19402853. Exclusion Code: X4. [PubMed: 17515738] [CrossRef]

700.

von Wachter M, Junger S, Renz D, et al. Psychosocial assessment and health care utilization after coronary bypass surgery. Gesundheitswesen. 2000 Aug–Sep;62(8–9):451–6. doi: 10.1055/s-2000-12614. PMID: WOS:000089270900007. Exclusion Code: X1. [PubMed: 11037671] [CrossRef]

701.

Votto JJ, Scalise PJ, Barton RW, et al. An analysis of clinical outcomes and costs of a long term acute care hospital. J Med Econ. 2011;14(2):141–6. doi: 10.3111/13696998.2010.551163. PMID: 21351183. Exclusion Code: X1. [PubMed: 21241209] [CrossRef]

702.

Wajnberg A, Hwang U, Torres L, et al. Characteristics of frequent geriatric users of an urban emergency department. J Emerg Med. 2012 Aug;43(2):376–81. doi: 10.1016/j.jemermed.2011.06.056. PMID: 21999906. Exclusion Code: X4. [PubMed: 22040771] [CrossRef]

703.

Walker BH, McCown JS, Bowser D, et al. An assessment of emergency department use among Mississippi’s Medicaid population. J Miss State Med Assoc. 2015 May;56(5):120–4. PMID: 25886658. Exclusion Code: X1. [PubMed: 26182673]

704.

Walter LJ, Ackerson L, Allen S. Medicaid chemical dependency patients in a commercial health plan: do high medical costs come down over time? J Behav Health Serv Res. 2005 Jul–Sep;32(3):253–63. PMID: 15628650. Exclusion Code: X1. [PubMed: 16010182]

705.

Wammes JJG, van der Wees PJ, Tanke MAC, et al. Systematic review of high-cost patients’ characteristics and healthcare utilisation. Family caregiving: a vision for the future. BMJ Open. 2018 Sep 8; Mar;8(9):e023113. doi: 10.1136/bmjopen-2018-023113; . PMID: 28774786. Exclusion Code: X7. [PMC free article: PMC6129088] [PubMed: 30196269] [CrossRef]

706.

Wang D, Ing C, Blinderman CD, et al. Latent class analysis of specialized palliative care needs in adult intensive care units from a single academic medical center. J Pain Symptom Manage. 2019 Jan;57(1):73–8. doi: 10.1016/j.jpainsymman.2018.10.270. PMID: WOS:000454242100019. Exclusion Code: X1. [PMC free article: PMC6310624] [PubMed: 30315914] [CrossRef]

707.

Wang L, Porter B, Maynard C, et al. Predicting risk of hospitalization or death among patients receiving primary care in the Veterans Health Administration. Med Care. 2013 Apr;51(4):368–73. doi: 10.1097/MLR.0b013e31827da95a. PMID: 23269113. Exclusion Code: X1. [PubMed: 23269113] [CrossRef]

708.

Washington C, Turbow S. Timing of hospital follow-up does not impact time to readmission among a population of high-utilizers. J Gen Intern Med. 2017 Apr;32:S355–S. PMID: WOS:000440259001131. Exclusion Code: X1.

709.

Wasson JH, Ahles T, Johnson D, et al. Resource planning for patient-centered, collaborative care. J Ambul Care Manage. 2006;29(3):207–14. doi: 10.1097/00004479-200607000-00005. Exclusion Code: X1. [PubMed: 16788353] [CrossRef]

710.

Watase H, Hagiwara Y, Chiba T, et al. Multicentre observational study of adults with asthma exacerbations: who are the frequent users of the emergency department in Japan? BMJ Open. 2015 Apr 28;5(4):e007435. doi: 10.1136/bmjopen-2014-007435. PMID: 25246521. Exclusion Code: X1. [PMC free article: PMC4420980] [PubMed: 25922104] [CrossRef]

711.

Waxmonsky JA, Giese AA, McGinnis GF, et al. Colorado access’ enhanced care management for high-cost, high-need Medicaid members: preliminary outcomes and lessons learned. J Ambul Care Manage. 2011 Apr–Jun;34(2):183–91. doi: 10.1097/JAC.0b013e31820f64be. PMID: 21785095. Exclusion Code: X1. [PubMed: 21415616] [CrossRef]

712.

Webster F, Rice K, Bhattacharyya O, et al. The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings. International Journal for Equity in Health. 2019 Jul;18:8. doi: 10.1186/s12939-019-1010-6. PMID: WOS:000474558100002. Exclusion Code: X6. [PMC free article: PMC6611020] [PubMed: 31272466] [CrossRef]

713.

Weeks DL, Daratha KB, Towle LA. Diabetes prevalence and influence on resource use in Washington state inpatient rehabilitation facilities, 2001 to 2007. Arch Phys Med Rehabil. 2009 Nov;90(11):1937–43. doi: 10.1016/j.apmr.2009.06.008. PMID: 19851051. Exclusion Code: X1. [PubMed: 19887220] [CrossRef]

714.

Weil AR. Community Care For High-Need Patients. Health Aff (Millwood). 2019 Jun;38(6):891. doi: 10.1377/hlthaff.2019.00553. PMID: 32384483. Exclusion Code: X9. [PubMed: 31158007] [CrossRef]

715.

Weilburg JB, Wong HJ, Sistrom CL, et al. Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population. Psychiatr Serv. 2018 Dec 1;69(12):1230–7. doi: 10.1176/appi.ps.201800083. PMID: 28679819. Exclusion Code: X9. [PubMed: 30256183] [CrossRef]

716.

Weiner JZ, McCloskey JK, Uratsu CS, et al. Primary Care Physician Stress Driven by Social and Financial Needs of Complex Patients. J Gen Intern Med. 2019 Jun;34(6):818–9. doi: 10.1007/s11606-018-4815-x. Exclusion Code: X1. [PMC free article: PMC6544720] [PubMed: 30623384] [CrossRef]

717.

Weiner S, Schwartz A, Altman L, et al. Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System. JAMA Netw Open. 2020 Jul 1;3(7):e209644. doi: 10.1001/jamanetworkopen.2020.9644. PMID: 32735338. Exclusion Code: X1. [PMC free article: PMC7395234] [PubMed: 32735338] [CrossRef]

718.

Weir RC, Proser M, Jester M, et al. Collecting Social Determinants of Health Data in the Clinical Setting: Findings from National PRAPARE Implementation. J Health Care Poor Underserved. 2020 May;31(2):1018–35. doi: 10.1353/hpu.2020.0075. PMID: WOS:000539399800039. Exclusion Code: X9. [PubMed: 33410822] [CrossRef]

719.

Weiss Larry P. The identification of emotional disorders among high utilizers of medical care services: Adelphi; 1984. Exclusion Code: X7.

720.

Weiss SJ, Ernst AA, Ong M, et al. Effect of a social services intervention among 911 repeat users. Am J Emerg Med. 2005 Jul;23(4):492–6. doi: 10.1016/j.ajem.2004.11.003. PMID: 15379078. Exclusion Code: X1. [PubMed: 16032618] [CrossRef]

721.

Weissman GE, Kerlin MP, Yuan Y, et al. Potentially Preventable Intensive Care Unit Admissions in the United States, 2006–2015. Ann Am Thorac Soc. 2020 Jan;17(1):81–8. doi: 10.1513/AnnalsATS.201905-366OC. PMID: 30862996. Exclusion Code: X1. [PMC free article: PMC6944341] [PubMed: 31581801] [CrossRef]

722.

Wharam JF, Landon BE, Galbraith AA, et al. Emergency department use and subsequent hospitalizations among members of a high-deductible health plan. JAMA. 2007 Mar 14;297(10):1093–102. doi: 10.1001/jama.297.10.1093. PMID: 17722755. Exclusion Code: X1. [PubMed: 17356030] [CrossRef]

723.

Wherry LR, Burns ME, Leininger LJ. Using self-reported health measures to predict high-need cases among Medicaid-eligible adults. Health Serv Res. 2014 Dec;49 Suppl 2:2147–72. doi: 10.1111/1475-6773.12222. PMID: 24925967. Exclusion Code: X1. [PMC free article: PMC4241135] [PubMed: 25130916] [CrossRef]

724.

Whitson HE, Sanders LL, Pieper CF, et al. Correlation between symptoms and function in older adults with comorbidity. J Am Geriatr Soc. 2009 Apr;57(4):676–82. doi: 10.1111/j.1532-5415.2009.02178.x. PMID: 19282797. Exclusion Code: X1. [PMC free article: PMC2674624] [PubMed: 19392960] [CrossRef]

725.

Whittington JW, Kontz C, Craig C, et al. Bright spots for patients with complex needs. Institute for Healthcare Improvement; 2014. Exclusion Code: X7.

726.

Wier Guilhardi LM. An initial case study of a readmission and emergency department revisit reduction program for high utilizer patients at a large community hospital system in Massachusetts: ProQuest Information & Learning; 2018. Exclusion Code: X1.

727.

Wier Guilhardi LM. An Initial Case Study of a Readmission and Emergency Department Revisit Reduction Program for High Utilizer Patients at a Large Community Hospital System in Massachusetts. Boston University, ProQuest Dissertations Publishin; 2018. Exclusion Code: X1.

728.

Wiler J, Pines JM, Ward MJ. Value and quality innovations in acute and emergency care. Cambridge, United Kingdom: Cambridge University Press; 2017. Exclusion Code: X1.

729.

Williams BC. Limited effects of care management for high utilizers on total healthcare costs. Am J Manag Care. 2015 Apr;21(4):E244–E6. PMID: WOS:000358656900001. Exclusion Code: X1. [PubMed: 26244786]

730.

Williams BC, Paik JL, Haley LL, et al. Centralized care management support for ‘high utilizers’ in primary care practices at an academic medical center. Care Management Journals. 2014;15(1):26–33. doi: 10.1891/1521-0987.15.1.26. PMID: 107897595. Language: English. Entry Date: 20140327. Revision Date: 20150712. Publication Type: Journal Article. Exclusion Code: X1. [PubMed: 24761538] [CrossRef]

731.

Williamson AE, Johnson PC, Mullen K, et al. The disappearance of the “revolving door” patient in Scottish general practice: successful policies. BMC Fam Pract. 2012 Oct 4;13:95. doi: 10.1186/1471-2296-13-95. PMID: 22712694. Exclusion Code: X1. [PMC free article: PMC3528483] [PubMed: 23035887] [CrossRef]

732.

Wilson K, Mottram P, Hussain M. Survival in the community of the very old depressed, discharged from medical inpatient care. Int J Geriatr Psychiatry. 2007 Oct;22(10):974–9. doi: 10.1002/gps.1773. PMID: WOS:000250237800006. Exclusion Code: X1. [PubMed: 17299805] [CrossRef]

733.

Wilson M, Guta A, Waddell K, et al. The impacts of accountable care organizations on patient experience, health outcomes and costs: a rapid review. J Health Serv Res Policy. 2020;25(2):130–8. doi: 10.1177/1355819620913141. Exclusion Code: X1. [PubMed: 32321282] [CrossRef]

734.

Wolff JL, Spillman B. Older adults receiving assistance with physician visits and prescribed medications and their family caregivers: prevalence, characteristics, and hours of care. J Gerontol B Psychol Sci Soc Sci. 2014 Nov;69 Suppl 1:S65–72. doi: 10.1093/geronb/gbu119. PMID: 24749700. Exclusion Code: X1. [PMC free article: PMC4303066] [PubMed: 25342825] [CrossRef]

735.

Wong E, Guo R, Yoon J, et al. Impact of vha’s primary intensive care management program on dual system use. Health Serv Res. 2020;55(SUPPL 1):77–8. doi: 10.1111/1475-6773.13437. Exclusion Code: X1. [PubMed: 32919588] [CrossRef]

736.

Wong ES, Rosland AM, Fihn SD, et al. Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden. J Gen Intern Med. 2016 Dec;31(12):1467–74. doi: 10.1007/s11606-016-3833-9. PMID: 27503440. Exclusion Code: X1. [PMC free article: PMC5130955] [PubMed: 27503440] [CrossRef]

737.

Woo JH, Grinspan Z, Shapiro J, et al. Frequent users of hospital emergency departments in Korea characterized by claims data from the national health insurance: a cross sectional study. PLoS One. 2016;11(1):e0147450. doi: 10.1371/journal.pone.0147450. PMID: 27376308. Exclusion Code: X1. [PMC free article: PMC4726528] [PubMed: 26809051] [CrossRef]

738.

Woodhouse J, Peterson M, Campbell C, et al. The efficacy of a brief behavioral health intervention for managing high utilization of ED services by chronic pain patients. J Emerg Nurs. 2010 Sep;36(5):399–403. doi: 10.1016/j.jen.2009.02.008. PMID: 20837207. Exclusion Code: X3. [PubMed: 20837207] [CrossRef]

739.

Worthington DC. The role of psychology in integrated primary care for complex patients: Effects on mental health, utilization of medical services, and physiological markers of health: Virginia Commonwealth University; 2015. Exclusion Code: X1.

740.

Wu FM, Slightam CA, Wong AC, et al. Intensive outpatient program effects on high-need patients’ access, continuity, coordination, and engagement. Med Care. 2018 Jan;56(1):19–24. doi: 10.1097/mlr.0000000000000833. PMID: 29560072. Exclusion Code: X1. [PubMed: 29087980] [CrossRef]

741.

Wu J, Grannis SJ, Xu H, et al. A practical method for predicting frequent use of emergency department care using routinely available electronic registration data. BMC Emerg Med. 2016 Feb 9;16:12. doi: 10.1186/s12873-016-0076-3. PMID: 26860825. Exclusion Code: X1. [PMC free article: PMC4748445] [PubMed: 26860825] [CrossRef]

742.

Wyman MF, Liebzeit D, Voils CI, et al.?Hopes and wishes?: Goals of high -need, high -cost older patients and their caregivers. Patient Educ Couns. 2020 Jul;103(7):1428–34. doi: 10.1016/j.pec.2020.02.022. PMID: WOS:000540048500021. Exclusion Code: X1. [PMC free article: PMC7286795] [PubMed: 32098745] [CrossRef]

743.

Wyte-Lake T, Claver M, Johnson-Koenke R, et al. Hurricanes Harvey, Irma, and Maria: Exploring the Role of Home-Based Care Programs. Disaster Med Public Health Prep. 2020 Feb;14(1):119–24. doi: 10.1017/dmp.2019.158. PMID: WOS:000524927400020. Exclusion Code: X1. [PMC free article: PMC7064407] [PubMed: 32014082] [CrossRef]

744.

Xiang X, Zuverink A, Rosenberg W, et al. Social work-based transitional care intervention for super utilizers of medical care: A retrospective analysis of the bridge model for super utilizers. Soc Work Health Care. 2019;58(1):126–41. doi: 10.1080/00981389.2018.1547345. PMID: 2018-59710-001. Exclusion Code: X1. [PubMed: 30424717] [CrossRef]

745.

Xin H. How do high cost-sharing policies for physician care affect inpatient care use and costs among people with chronic disease? J Ambul Care Manage. 2015 Apr–Jun;38(2):100–8. doi: 10.1097/jac.0000000000000050. PMID: 25722302. Exclusion Code: X1. [PubMed: 25748258] [CrossRef]

746.

Xin H. High-cost sharing policies and non-urgent emergency department visits. Int J Health Care Qual Assur. 2018 Aug 13;31(7):735–45. doi: 10.1108/ijhcqa-05-2017-0089. PMID: 31980246. Exclusion Code: X1. [PubMed: 30354887] [CrossRef]

747.

Xin H, Harman JS, Yang Z. How do high cost-sharing policies for physician care affect total care costs among people with chronic disease? J Insur Med. 2014;44(1):38–48. PMID: 16636909. Exclusion Code: X1. [PubMed: 25004597]

748.

Xing J, Goehring C, Mancuso D. Care coordination program for Washington State Medicaid enrollees reduced inpatient hospital costs. Health Aff (Millwood). 2015 Apr;34(4):653–61. doi: 10.1377/hlthaff.2014.0655. PMID: 25847649. Exclusion Code: X1. [PubMed: 25847649] [CrossRef]

749.

Yan J, Linn KA, Powers BW, et al. Applying Machine Learning Algorithms to Segment High-Cost Patient Populations. J Gen Intern Med. 2019 Feb;34(2):211–7. doi: 10.1007/s11606-018-4760-8. PMID: 27087391. Exclusion Code: X4. [PMC free article: PMC6374273] [PubMed: 30543022] [CrossRef]

750.

Yedidia MJ. Competencies for engaging high-needs patients in primary care. Healthc (Amst). 2018 Jun;6(2):122–7. doi: 10.1016/j.hjdsi.2017.06.005. PMID: 27613732. Exclusion Code: X1. [PubMed: 29217389] [CrossRef]

751.

Yip J, Nishita CM, Crimmins EM, et al. High-cost users among dual eligibles in three care settings. J Health Care Poor Underserved. 2007 Nov;18(4):950–65. doi: 10.1353/hpu.2007.0109. PMID: 24215036. Exclusion Code: X1. [PubMed: 17982217] [CrossRef]

752.

Yotani N, Ishiguro A, Sakai H, et al. Factor-associated caregiver burden in medically complex patients with special health-care needs. Pediatr Int. 2014 Oct;56(5):742–7. doi: 10.1111/ped.12339. PMID: 22899484. Exclusion Code: X1. [PubMed: 24628805] [CrossRef]

753.

Zhang YK, Grinspan Z, Khullar D, et al. Developing an actionable patient taxonomy to understand and characterize high-cost Medicare patients. Healthcare-the Journal of Delivery Science and Innovation. 2020 Mar;8(1):6. doi: 10.1016/j.hjdsi.2019.100406. PMID: WOS:000529324400008. Exclusion Code: X9. [PubMed: 31918975] [CrossRef]

754.

Zulman D. Evaluating innovative care models for high-utilizing patients. VA Palo Alto Health Care System, Center for Innovation to Implementation. 2013. https://www​.hsrd.research​.va.gov/research/abstracts​.cfm?Project_ID=2141703149. Exclusion Code: X1.

755.

Zulman DM, Chang ET, Wong A, et al. Effects of intensive primary care on high-need patient experiences: survey findings from a Veterans Affairs randomized quality improvement trial. J Gen Intern Med. 2019 May;34(Suppl 1):75–81. doi: 10.1007/s11606-019-04965-0. PMID: 30789650. Exclusion Code: X9. [PMC free article: PMC6542922] [PubMed: 31098977] [CrossRef]

756.

Zulman DM, Pal Chee C, Ezeji-Okoye SC, et al. Effect of an intensive outpatient program to augment primary care for high-need Veterans Affairs patients: a randomized clinical trial. JAMA Intern Med. 2017 Feb 1;177(2):166–75. doi: 10.1001/jamainternmed.2016.8021. PMID: 28783974. Exclusion Code: X1. [PubMed: 28027338] [CrossRef]

Detailed Results Tables