The Challenge Nationally, 1% of patients account for a disproportionate share of healthcare costs (22%) related to emergency department (ED) utilization, hospitalization and hospital readmissions. Such patients include those with diabetes, mental health and substance use disorders, end-stage renal disease, sickle cell disease and other chronic health conditions. To help curb these costs, in 2017, UVA Health piloted its Medicine HOME program to reduce hospitalization and readmissions among frequently hospitalized adult patients. UVA began the program with a cohort of 10 adult patients with sickle cell disease. At the time, these patients accounted for 7% of all 30-day readmissions to general medicine services.

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