Pilot program identifies the cause of frequent ED visits; patients overcome barriers
After reading this article, you will be able to:
- Describe the University Health Care Center’s ED Visit Reduction Pilot Program
- Recall how UHCC staff members overcame barriers that prevented patients from normal healthcare avenues
Coughing children, teens with gunshot wounds, patients with broken bones; for many facilities, the ED is a chaotic and crowded place.
Compounding the situation, there is a population of patients who use the ED as their main access point to healthcare. Often, these patients’ problems are not emergencies and care could be better provided by primary care providers (PCP) or outpatient clinics. However, mental, social, economic, and logistical barriers prevent patients from pursuing the normal avenues to healthcare, and the ED is typically the easiest option.
Facilities cannot turn these patients away, as it goes against medical ethics and the Emergency Medical Treatment & Active Labor Act of 1986. So facilities such as University Health Care Center (UHCC) in Syracuse, NY, create programs to work with such ED regulars to provide more suitable care and overcome potential barriers.
Finding the prospective patients
UHCC modeled its program for handling frequent ED visitors after one established at Swedish Medical Center in Englewood, CO, says Pamela O’Donnell, RN, BSN, ED case manager at UHCC. “I read an article about ED overcrowding and ‘frequent fliers’ written by Sheryl Swan, RN, at Swedish Medical Center and then adapted their program to our situation,” says O’Donnell.
To find the sample patient population for the pilot program, the hospital’s information technology department looked at all the ED admissions from the previous six months and compiled a list of the 50 most frequent ED visitors.
“Ideally, we would be able to address each of those top 50 visitors,” O’Donnell says. Instead, the committee of social workers, case managers, and directors decided to deal with a small group and evaluate the program. Based on those results, the committee would decide whether the hospital could take on a larger group.
The committee identified patients with PCPs in the same hospital system. It eliminated patients with sickle- cell anemia, which requires frequent ED visits, and mental health problems, which limit a patient’s ability to comply with healthcare regimens.
After applying those filters, the committee had five patients who met the hospital’s desired criteria:
- More than 10 visits to the ED in the past year
- Have a PCP at UHCC (previously or currently)
- Have no diagnosed psychiatric issues at this time
Those five would be the prospective patients used in the hospital’s Emergency Department Visit Reduction Pilot Program.
Identifying and overcoming barriers
Using forms and tools developed by the committee (see p. 8), ED social workers and case managers interacted with the prospective patients each time they presented to the ED or the outpatient setting. During the first encounter, patients answered basic questions, including:
- Why they chose the ED instead of contacting their PCP
- What mode of transportation they used to get to the ED
- Whether there had been any recent changes in their family or living situations
This initial assessment revealed several barriers that led to frequent ED visits. For example, one man did not have a phone service, so he could not contact his PCP to make an appointment or ask questions about his medications. However, he could call 911 from his phone, which meant he presented to the ED whenever he had a medical issue. In this situation, the patient’s family offered to add the patient on their family cell phone plan.
Another patient’s anxiety proved to be his biggest barrier. “This particular patient would always visit the emergency room at night. We talked and we realized that he had terrible insomnia and terrible anxiety,” says Taisa Reynolds, LMSW, social worker at UHCC.
The UHCC staff was able to get this patient treatment for his anxiety and insomnia, which in turn greatly reduced his visits to the ED.
Instead of merely treating the condition the patient presented for—frequent chest pain or stomach pain—on that particular occasion, the UHCC staff was able to also address the root cause of the patient’s frequent visits.
Overcoming systemic barriers
In many cases, social workers and case managers at UHCC found they were filling in the gaps left by a patient’s PCP. Reynolds believes the problem at UHCC is part of a nationwide shortage of PCPs. “In my opinion, we don’t have enough primary care. PCPs don’t have enough time to have one-on-one time with patients because their caseload is ridiculous,” she says.
Reynolds says PCPs spend a majority of their time overseeing the overall medical piece of the patient’s care—making sure the patient sees the right specialists and making referrals—but that doesn’t leave much time to address the patient’s social and environmental issues.
O’Donnell and Reynolds say the prospective patients have reacted positively to the program.
“One patient in particular was very excited that someone had taken an interest in his specific case,” Reynolds says. “He seemed all for it and really enjoyed the one-on-one attention.”
Each time a social worker or case manager interacted with a prospective patient, he or she used forms to track the patient’s progress. UHCC staff members saved the forms to a shared computer network so all committee members could access the documents and make changes.
After interacting and tracking the patients’ progress for six months, the committee compared the number of ED visits during that time to the previous six-month period:
- Patient #1 visited 25 times compared to 35 visits in the previous six-month period.
- Patient #2 visited 15 times compared to 29 visits in the previous six months. Of those 15 visits, seven resulted in admission to the hospital.
- Patient #3 visited four times compared to eight in the previous six-month period.
- Patient #4 visited once compared to four times in the previous six-month period. This patient had been a frequent visitor to the pediatric ED in 2007 and has successfully made the transition to adult medicine, thus greatly reducing visits.
- Patient #5 had no visits compared to five ED visits in the previous six months. The patient was enrolled in the Enriched Resources for Independent Living program, enabling the patient to receive meals, medications, and case management interventions.
Adapted from Case Management Monthly, December 2009, HCPro, Inc.
Name ___________________________________ DOB ______ MR# _________ Address _____________________________________
Phone number (home) _____________ (cell) ________________ (work) _________________
PCP _______________________ Office number _________________
Specialty physicians/clinic ____________ Office number _______
Reason for visit on initial assessment ______________________
Why did you come to the ED rather than contacting your PCP?
Instructed by PCP _____ Office not open _____ Financial issues with PCP _____
Financial issues re: RX ________ Other ________________________________________________
Medicaid _____ Limitations to Medicaid _____ Medicare _____
Commercial _____ Self-pay _____ Prescription coverage/copay _____
Last ED visit __________ Number of ED visits this year ______
Last PCP visit _________ Number of PCP visits scheduled _____ Number of PCP visits attended ______
Would you sign a release of information so we can talk with other providers outside of the hospital?
Date signed and placed in medical record ____________
Do you use community resources?
Home care nursing/HA/PT agency ______ Durable medical equipment ______ Case manager ______
Outside agency (Enable, SHA, OCM, etc.) ______ Other ____________________________
Are there financial problems? ____________________________________________________________________________________
Are there any recent changes in your living situation? ______________________________________________________________
Do you have family/friends that you trust/depend on? Name ___________________ Phone number _____________________
Can we talk with them about your specific issues and include them in your plan of care? _____________________________
Transportation: Drive self ____ County transportation ____ Family/friend ____ Other ____
What is the highest grade you attended in school? ________________________________________________________________
Do you have any diagnosis that affects how you read, reason, or make decisions? ____________________________________
What do you see as the main problem, and how do you see us assisting you in that area? ____________________________
Do you recognize situations (e.g., weather changes, family situations) that affect your health? ________________________
Source: Pamela O’Donnell, ED case manager, University Health Care Center, Syracuse, NY.