An Intensive Intervention to Reduce Readmissions for Frequently Hospitalized Patients: the CHAMP Randomized Controlled Trial

Bruce L. Henschen*, Maria E. Theodorou, Margaret Chapman, McKay K. Barra, Abby Toms, Kenzie A. Cameron, Shuhan Zhou, Chen Yeh, Jungwha Lee, Kevin J. O’Leary

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Background: A small number of patients are disproportionally readmitted to hospitals. The Complex High Admission Management Program (CHAMP) was established as a multidisciplinary program to improve continuity of care and reduce readmissions for frequently hospitalized patients. Objective: To compare hospital utilization metrics among patients enrolled in CHAMP and usual care. Design: Pragmatic randomized controlled trial. Participants: Inclusion criteria were as follows: 3 or more, 30-day inpatient readmissions in the previous year; or 2 inpatient readmissions plus either a referral or 3 observation admissions in previous 6 months. Interventions: Patients randomized to CHAMP were managed by an interdisciplinary team including social work, physicians, and pharmacists. The CHAMP team used comprehensive care planning and inpatient, outpatient, and community visits to address both medical and social needs. Control patients were randomized to usual care and contacted 18 months after initial identification if still eligible. Main Measures: Primary outcome was number of 30-day inpatient readmissions 180 days following enrollment. Secondary outcomes were number of hospital admissions, total hospital days, emergency department visits, and outpatient clinic visits 180 days after enrollment. Key Results: There were 75 patients enrolled in CHAMP, 76 in control. Groups were similar in demographic characteristics and baseline readmissions. At 180 days following enrollment, CHAMP patients had more inpatient 30-day readmissions [CHAMP incidence rate 1.3 (95% CI 0.9–1.8) vs. control 0.8 (95% CI 0.5–1.1), p=0.04], though both groups had fewer readmissions compared to 180 days prior to enrollment. We found no differences in secondary outcomes. Conclusions: Frequently hospitalized patients experienced reductions in utilization over time. Though most outcomes showed no difference, CHAMP was associated with higher readmissions compared to a control group, possibly due to consolidation of care at a single hospital. Future research should seek to identify subsets of patients with persistently high utilization for whom tailored interventions may be beneficial. Trial Registration: identifier: NCT03097640;

Original languageEnglish (US)
Pages (from-to)1877-1884
Number of pages8
JournalJournal of general internal medicine
Issue number8
StatePublished - Jun 2022


  • care models
  • care transitions
  • continuity of care
  • randomized controlled trial
  • readmissions

ASJC Scopus subject areas

  • Internal Medicine


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