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EVALUATING A CONSISTENT CARE PROGRAM FOR A HOSPITAL EMERGENCY DEPARTMENT TO REDUCE FREQUENT VISITS.

ABSTRACT

Patients utilizing Emergency Departments (EDs) frequently have become an increasing concern to hospitals across the nation as it creates inconsistent care for patients and increased care costs for patients, hospitals, and insurers. Over a period of 4 years, a Midwest regional hospital identified an upward trend in these visits to the ED and implemented a case management intervention that included individualized care planning and a social work case manager for 103 patients. During the first year of the program, ED visits for this patient population were reduced by 68% and ED charges decreased by $1.1 million. This manuscript has implications for EDs, behavioral health units, out-patient services, and medical homes.

INTRODUCTION

Patients utilizing Emergency Departments (EDs) frequently for healthcare needs have become an increasing concern to hospitals, payers and consumers across the nation. This manuscript is a descriptive single case study of how a Midwest regional hospital ED implemented an interdisciplinary program, known as the Emergency Department Consistent Care Program (EDCCP), to reduce frequent ED visits. The process of how this hospital identified the most common presenting complaints for 103 frequent ED users and developed six care plan tracks that were subsequently used to create individualized care plans will be described. The manuscript also describes how a social work case manager was utilized to coordinate patient care with the focus of facilitating care in the most appropriate setting.

BACKGROUND- LITERATURE REVIEW

Frequent-access patients account for a disproportionately large number of ED visits, with estimates from 21% to 30% of all ED visits being made by these patients (LaCalle, Rabin, & Genes, 2013; Sempere-Selva, Peiro, Sendra-Pina, Martinez-Espin, & Lopez-Aguilera, 2001; Sun, Burstin, & Brennan, 2003). Patients who had four or more visits in a 12-month period were 28% to 38% more likely to continue to have high ED utilization and after 2 years of frequent use, these patients were 56% more likely to continue being frequent users (LaCalle & Rabin, 2010). While there is no standard definition of the number of visits needed to qualify a person as a frequent user of emergency services, a review of the literature found that most studies defined frequent use between two and 12 visits per year, with four visits being most common (LaCalle & Rabin, 2010).

Literature shows the majority of frequent ED users do have public or private insurance, a primary care provider (PCP), and/or access to healthcare (LaCalle & Rabin, 2010). Unfortunately, patients have indicated that EDs are more convenient and satisfy the need for a perceived urgency. Raven, Kotchko, & Gould ( 2011) concluded patients believe use of the ED is free or less expensive than primary care, while others are not even aware of available primary care services and are unfamiliar with walk-in clinics. Additional factors related to frequent use of the emergency department include non-financial access barriers such as language/cultural barriers, transportation, child care, and office hours (Shippee, Shippee, Hess, & Beebe, 2014). Locker, Baston, Mason, & Nicholl (2007) identified patients with psychiatric problems or issues related to alcohol as a predictor of frequent ED use. Limited interventions to reduce frequent ED use exist in the literature. Therefore, a need exists to explore methods to decrease the number of visits by frequent-use patients.

Crane, Collins, Hall, Rochester, & Patch (2012) and Hunt, Weber, Showstack, Colby, & Callaham (2006) asserted designated staff for patient follow-up and case management has been found to reduce the frequency of ED visits and improve patient outcomes. In 2002, California created a frequent access program which reduced the number of frequent access patients' visits by 61% in 2 years (Corporation for Supportive Housing, 2008). This particular program used a combination of case management, connections with primary care physicians, housing agencies, psychiatric and mental health agencies, and coordination with other hospitals to reduce ED visits. Minnesota Health Care Program's study concluded efforts towards educating patients regarding available alternative services and addressing "non-financial barriers" such as transportation, child care, and social situations would help reduce frequent ED visits. Other studies further emphasized "efforts to ensure effective linkage to a primary care home" (Billings & Raven, 2013, p. 2107) and interventions that strengthen continuity of care (Vandyk, Harrison, VanDenKerkhof, Graham, & Ross-White, 2013) across the patient's care continuum.

Objectives

The overall purpose of this single case study was to provide efficient cost-effective high-quality care for patients who frequently accessed ED services for care and to facilitate care in the most appropriate setting. Therefore, the objective for this quality improvement project was to measure the effectiveness of a social work case manager guided multiple disciplinary approach and the use of individualized care plans to reduce visits to the ED. Success was measured by a reduction of frequent users' visits to the ED.

Setting

This single case study took place in a 532-bed Midwest regional non-profit hospital in an urban location of a rural state. This Magnet accredited hospital has a 34-bed Level 3 trauma center ED serving approximately 55,000 patients annually.

Implementation Methods

Studies referenced in the literature defined 2 to 12 visits per year to as frequent use. The EDCCP committee opted to begin with a 12 visit per 12 month criteria for inclusion into the program. In October 2011, the Performance Improvement Department produced baseline data for 103 patients meeting the following criteria: age 18 years and over having 12 or more ED visits in the previous 12 months. The 103 identified patients demonstrated continuation of a four-year upward trend in frequent use patients from 41 in 2007 to 83 in 2008, 85 in 2009, and 98 in 2010 (see Table 1).

As indicated by the literature, reasons for choosing the ED for care among frequent users is multifaceted, and therefore a multidisciplinary approach was necessary. In 2011, an interdisciplinary team of social workers, physicians, nurses, data analysis, and leadership representatives was formed to examine this population's ED visits. The team became known as the Emergency Department Consistent Care Program (EDCCP) committee, with the charge of reducing frequent ED visits.

The committee's Emergency Department Physicians (EDP) examined the top 22 principal diagnoses for the identified 103 patients. The principal diagnoses were categorized into abdominal pain, chest pain, headache, back pain, general pain, and behavioral health (see Table 2) which later became established plan of care tracks (see Table 3). Each evidence- based physician-developed plan of care track outline recommendations for consistent care when the frequent user presented to the ED. Step one for all care plan tracks is an EDP evaluation and necessary diagnostic tests. Additional steps include guidelines for treatment and recommendations for pain management and discharge. The following care plan tracks were assigned to EDCCP patients: general pain (72 participants) behavioral health (30 participants), abdominal pain (13 participants), back pain (12 participants), headache (three participants), and chest pain (two participants). Of the EDCCP patients, approximately one-third (29.1%) were assigned a behavioral health track care plan. While every patient was assigned at least one care plan track, several patients were assigned more than one.

With the hospital's Institutional Review Board's (IRB) approval, the EDCCP case study officially began on January 1, 2012 and concluded on December 31, 2012. ED staff were educated about the program's development and implementation during staff meetings, during pre-brief (meeting before shifts begin), and via e-mails. Staff was informed of the program's purpose, criteria for enrollment, EDCCP procedures, and staff's role in providing care for these patients. Lastly, staff was shown how to identify program participants in the electronic medical record.

Patients were mailed a notice of their enrollment into the EDCCP by certified mail to ensure the protection of the patient's medical information. The mailing included a letter of introduction, a copy of the patient's ED care plan for review, and a Release of Information (ROI). The letter of introduction informed the patients that because of their number of visits to the ED, they had been enrolled in the EDCCP. The letter also included the purpose of the program was to ensure that the patients' medical needs were being met in the most appropriate setting. Further, a social work case manager's assistance was offered if patients were having difficulty having their medical needs met.

A full-time case manager was hired with funds from a $50,000 community grant from TransAmerica. The case manager's primary role was to establish a relationship with the patients to ascertain needs and barriers. The case manager explained the EDCCP and the role of the case manager and provided an opportunity to answer any questions patients had regarding the program and their participation. Discussions took place with patients regarding the role of a PCP and the roles and responsibilities of a patient. Patient responsibilities included: utilizing primary care for well visits, acute visits and on-going medical conditions; appointment management; and follow-up care. Assistance was provided by the case manager to apply for insurance, establish primary care if needed, schedule appointments, secure transportation, and navigate the health care system.

To provide increased care coordination across all health care settings, education was provided community providers including the local federally funded community health clinic, mental health services, area hospitals and PCPs. The PCPs contributed additional recommendations to the ED care plan based on the existing out-patient plan of care. The addition of the PCPs involvement facilitated patients receiving consistent care both in and out of the ED.

RESULTS

The project employed a sample of 103 patients that met the criteria of 12 or more ED visits in the 12 months between November 2010 and October 2011. Of these patients, 64 were female (62%) and 39 were male (38%). The mean age was 38.2 years and race included one Asian (1%), nine Black or African American (9%), one Hispanic/Latino (1%), 90 White/Caucasian (87%) and two Unknown (2%) (see Table 4). Payer sources included Medicaid (36%), Medicare (29%), self-pay (19%) and 16% commercial health insurance (see Table 5).

The 103 EDCCP participants' baseline measurement was 1,679 ED visits in 2011. As a result of the ED care plan and case management intervention, ED visits among the frequent user population drastically reduced to 537 at the end of 2012. The reduction of ED visits equated to a $1,113,728 decrease in hospital charges (see Tables 6, 7, 8). The frequent ED users made up 3% of the annual ED visits. The creation of the EDCCP care plan tracks and a fulltime social work case manager reduced ED visits of the 103 patients from 16 visits per year per patient to five visits per year per patient. By December 31, 2012, only nine of the 103 patients continued to meet the 12 visits per rolling 12-month criteria for enrollment in the EDCCP comprising 1% of all annual ED visits.

DISCUSSION

Seventy-five percent of the 103 EDCCP participants reported having a source of primary care. This was consistent with LaCalle et al. (2013) who reported the majority of frequent users do have a PCP, access to healthcare and/or public or private insurance. Eighty-one percent of the EDCCP patients had insurance. Although the majority of frequent users visiting the ED have health insurance, the reimbursement rates for federally funded insurances and self-pay are significantly lower than those of commercial insurances. Federally funded insurances and self-pay were the top 3 payer sources (84%) covering 1400 of the 1679 baseline visit charges totaling $1,412,559.14. Conversely, commercial reimbursements covered the remaining 16% or 279 visit charges totaling $281,502.86.

Wajnberg et al. (2012) classified the most common illnesses with frequent ED users as cardiac, pulmonary, neurological, and gastrointestinal complaints. This finding is consistent with the EDCCP care plan tracks formed using the top principal diagnosis of the identified population. The project differed from the research performed by Sun et al. (2003), who indicated that advanced age and minority race were factors identified with frequent users. Conversely, the EDCCP participants' mean age was 38.2 years and race and gender were Caucasian and female. Billings and Raven (2013) concluded that mental illness is not the typical primary diagnosis seen in the ED, while Locker et al. (2007) recognized behavioral health as a predictor of frequent use of emergency services. Consistent with these two authors' conclusions, almost 30% of the EDCCP patients were assigned a behavioral health care plan track in addition to a pain care plan track.

Recommendations for Program Implementation and Sustainability

An interdisciplinary approach was essential in which each EDCCP committee member was actively engaged in process changes and invested in providing appropriate care for this patient population. Each discipline represented was able to assist in the promotion, education, and implementation of the program within the ED on a daily basis. After implementation of the program, the committee continued to meet monthly to review patient data generated from the hospital's performance improvement office, evaluate program implementation, discuss patient interventions, and address staff questions and concerns. Due to the significant reduction in overall ED visits and costs savings in the first year of implementation, the full-time social work case management position transitioned from being funded by the TransAmerican grant to being included in the hospital's ED annual budget.

The program continues to enroll patients who meet the criteria of 12 visits in the previous 12 months. In addition, the case manager takes referrals from ED Providers and ED social workers for patients who have current repeated visits, with the goal of helping patients find appropriate care before they reach the 12-visit criteria. Patients have been added monthly, with more than 450 patients in the program as of December 31, 2014. When patients have reduced their visits and have zero visits in the previous 6 months, the electronic flag in the medical record changes to a "graduate" status This indicates to staff that the patient has significantly reduced the use of emergency services.

Implications

It is ideal for patients to receive medical treatment in the most appropriate settings, which should be a goal for all patients, especially those patients who frequently utilize the ED. In our current fragmented health care system, patients often have to seek treatment from different providers for multiple conditions: mental health services, primary care and chronic disease management. Hospitals and clinics nationwide are looking for ways to coordinate patient's medical care and reduce frequent visits to the ED. This program serves as a model to provide such collaboration. Although the implementation of this program may reduce hospital revenue, as we move towards Accountable Care Organizations (ACOs) under the Affordable Care Act, there will be an increased emphasis placed on "bundled payments" and the need to collaborate with other providers to help manage patients' health. A case management program for frequent ED use patients improves quality of care and services by emphasizing patient involvement and empowering patients to seek medical care in the most appropriate health care setting. Due to the success of this program, the UnityPoint Health System has expanded the EDCCP to 10 of their affiliate hospitals in Iowa, Illinois, and Wisconsin. Implementing this strategy on a system wide level across a large area of the Midwest has the potential to positively impact population health.

REFERENCES

Billings, J., & Raven, M. C. (2013). Dispelling an urban legend: Frequent emergency department users have substantial burden of disease. Health Affairs, 32(12), 2099-2108.

Corporation for Supportive Housing. (2008). Summary report of evaluation findings: A dollars and sense strategy to reducing frequent use of hospital services. Retrieved from http://www.csh.org/index.cfm?fuseaction=Page.viewPage&pageId=4224&parentID=3803

Crane, S., Collins, L., Hall, J., Rochester, D., & Patch, S. (2012). Reducing the utilization by uninsured frequent users of the emergency department: Combining case management and drop-in group medical appointments. The Journal of the American Board of Family Medicine, 25(2), 184-191.

Hunt, K. A., Weber, E. J., Showstack, J. A., Colby, D. C., & Callaham, M. L. (2006). Characteristics of frequent users of emergency departments. Annals of Emergency Medicine, 48(1), 1-8.

LaCalle, E. J., & Rabin, E. J. (2010). Frequent users of emergency departments: The myths, the data, and the policy implications. Annals of Emergency Medicine, 56(1), 52-59.

LaCalle, E. J., Rabin, & E. J., & Genes, G. (2013). High-frequency users of emergency department care. Journal of Emergency Medicine, 44(6), 1167-1173.

Locker, T. E., Baston, S., Mason, S. M., & Nicholl, J. (2007). Defining frequent use of an urban emergency department. Emergency Medicine Journal, 24(6), 398-401.

Raven, M. C., Kotchko, S. M., & Gould, D. A. (2011). Can targeted messaging encourage PCP contact before ED visits? Managed Care, 20(3), 24-27.

Sempere-Selva, T., Peiro, S., Sendra-Pina, P., Martinez-Espin, C., & Lopez-Aguilera, I. (2001). Inappropriate use of an accident and emergency department: Magnitude, associated factors, and reasons--An approach with explicit criteria. Annals of Emergency Medicine, 37(6), 668-579.

Shippee, N. D., Shippee, T. P., Hess, E. P., & Beebe, T. J. (2014). An observational study of emergency department utilization among enrollees of Minnesota health care programs: Financial and non-financial barriers have different associations. BMC Health Services Research, 16:42. DOI: 10.1186\1472-6963-14-62.

Sun, B. C., Burstin, H. R., & Brennan, T. A. (2003). Predictors and outcomes of frequent emergency department users. Academic Emergency Medicine, 10(4), 320-328.

Vandyk, A. D., Harrison, M. B, VanDenKerkhof, E. G., Graham, I. D. & Ross-White, A. (2013). Frequent emergency department use by individuals seeking mental healthcare: A systematic search and review. Archives of Psychiatric Nursing, 27, 171-178.

Wajnberg, A., Hwang, U, Torres, L. & Yang, S. (2012). Characteristics of frequent geriatric users of an urban emergency department. The Journal of Emergency Medicine, 43(2), 367-381.

Marilyn Gerhold

Sallie Selfridge

St. Luke's Hospital, Cedar Rapids

Joan Copper

Coe College
Table 2
Principal Diagnoses

EDCCP Initial 103 Patients
Discharged Between 11/1/2010 and 10/31/2011
Top 22 Principal Diaganoses

786.5 Chest pain, unspecified     143
789 Abdominal pain                 94
724.2 Lumbago                      80
724.5 Backache, unspecified        66
784 Headache                       52
346.9 mention of status            48
338.29 Other chronic pain          32
599 Urinary tract infection        26
300 Anexiety state, unspeciefied   25
789.09 Abdominal pain              24
786.05 Shortness of breath         23
466 Acute bronchitis               22
789.03 Abdominal pain, right       21
787.03 Vomiting alone              19
845 Sprain of ankle                19
648.93 Other current               17
486 Pneumonia, organism            16
729.5 Pin in limb14                16
525.9 Unspecified disonder of      14
682.6 Cellulitis and abscess       13
780.2 Syncope and collapse         13
789.04 Abdominal pain, left        13

Table 3
Plan of Care Tracks

1. Chest pain:
   a. Chest pain protocol ordered by nursing.
   b. Patient will be evaluated by Emergency Department
      Provider (EDP).
   c. No opiates to be given for pain unless evidence of
      acute ischemia.
   d. Nitro SL will be given as per usual if SBP remains
      >100 mmHg.
   e. Toradol (if no allergies and medically appropriate)/GI
      cocktail may be given for pain.
   f. If any concern for unstable angina/acute coronary
      syndrome, appropriate cardiac consultation will be
      made.
   g. Patient will not be discharged with prescriptions for
      opiates.
2. Abdominal pain:
   a. Patient will be evaluated by EDP.
   b. Labs/radiology will be ordered at EDP discretion.
   c. No opiates will be given for pain.
   d. Zofran, ketorolac, GI cocktail, etc., may be given for
      pain.
   e. Patient will not be discharged with prescriptions for
      opiates.
3. Behavioral-health:
   a. Patient will be assessed for suicidal/homicidal
      ideation/psychosis by EDP. These will be handled as
      with every patient, labs as appropriate and admission
      as needed.
   b. If anxiety is driving the chief complaint, consider
      Vistaril or consult with psychiatrist.
   c. No home medication changes will be made by ED
      personnel. Contact patient's psychiatrist for further
      changes.
   d. Patient will not be discharged with prescriptions for
     benzos or opiates.
4. General pain:
   a. Patient will be assessed by EDP with labs/radiology
      at EDP discretion.
   b. Patient will not be offered opiates for acute pain
      control. Alternatives include dental blocks, Toradol,
      Tramadol, Haldol, Reglan and Benadryl, etc.
   c. Patient will not be discharged with opiate
      prescriptions.
5. Back pain:
   a. Patient will be assessed by EDP. X-ray or further
      imaging at discretion of EDP.
   b. Attempt intramuscular or oral pain control first with
      Toradol, Tramadol, Nubain, muscle relaxant--no
      further opiates will be given.
   c. IV placed only if continues with severe pain but no
      opiates will be given.
   d. Patient will be discharged without prescriptions for
      opiates. Consider non-narcotics, NSAID and muscle
      relaxants, physical therapy and primary care provider
      follow-up.
6. Headache
   a. Patient will be assessed by EDP with full neurologic
      exam.
   b. Imaging and further labs per EDP discretion.
   c. Patient will not receive narcotics for pain control.
      Consider Triptans, Toradol, Reglan/Compazine and
      Benadryl, Haldol IM, caffeine, Nubain.
   d. Patient will not be discharged home with prescription
   for opiates.

References: Agency for HealthCare Research and Quality (AHRQ) and
American College of Emergency Physicians (ACEP)

Table 4
Patient Demographic

Gender                     N=103    Percent

   - Female                64       62.1%
   - Male                  39       37.9%
Mean Age                   38.2
Race
   - Asian                  1        1.0%
   - Black or African       9        8.7%
     American
   - Hispanic/Latino        1        1.0%
   - White or Caucasian    90       87.4%
   - Unknown                2        1.9%

Table 6
Average Yearly Visits Per Patient

ED Consistent Care Program
Patients Who Received Care Plans in 2012

      Patients Volume=103

2011       16.3
2012        5.2
2013        4.0
2014        3.2

Patient Volume = 103

Table 7
Charges of Total Baseline Visits

ED Consistent Care Program
Patients Who Received Care Plans in 2012

      Patients Volume=103

2011     $1,694,062
2012       $580,334
2013       $484,369
2014       $472,616

Patient Volume = 103

Table 8
Total Number of ED Visits by Year

ED Consistent Care Program
Patients Who Received Care Plans in 2012

2011         1679
2012          537
2013          413
2014          334

Patient Volume = 103
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Article Details
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Author:Gerhold, Marilyn; Selfridge, Sallie; Copper, Joan
Publication:Journal of Health and Human Services Administration
Article Type:Report
Date:Jun 22, 2017
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