EDs slash unnecessary visits using interfaced computers, common protocols

Project aimed at boosting safety net pays financial dividends

Three Lincoln, NE-based EDs have joined forces to tackle two of the most nagging problems facing emergency departments today: The use of EDs for primary care services, and the growing number of uninsured or underinsured patients seeking emergency care.

The program, named Lincoln ED Connections, was designed to improve "safety net" services for the local population by finding them primary care "homes" with providers. How serious was the problem? In a 12-month period, the 12 people who made the highest number of visits to the two EDs resulted in $231,869 in unreimbursed care, according to Ruth Radenslaben, ED manager at Bryan Lincoln General Hospital (LGH) Medical Center. She oversees two EDs: one at Bryan LGH East, and another at Bryan LGH West.

Lincoln ED Connections officially began seeing patients in October 2005, she says. In the 12 months prior to enrolling, 34 patients made a total of 377 visits to Lincoln EDs, which is more than a visit a day by at least one of them. One such "frequent flier" made 96 trips to the two EDs.

In the first three months of the new program, those frequent flier visits have been reduced to 40. At an annualized figure of 160, that would represent more than a 50% reduction.

The program got its impetus when Bryan was involved in a grant several years ago from the Robert Wood Johnson Foundation several years ago that involved internal and communitywide data collection, Radenslaben recalls.

"One thing we learned was we had to improve the safety net service to the community, and they suggested we do it cooperatively with St. Elizabeth [Regional Medical Center]," she says. They found there wasn’t formal collaboration between safety net providers, Radenslaben says. "Access to primary care was limited, and we needed a better referral mechanism for patients who did not have medical homes."

In the summer of 2004, Bryan started working with Community Health Endowment, a dollar-granting group for the city, and with St. Elizabeth to get a better idea of the needs that existed. They learned that the potential safety net for nonemergent needs included primary care providers, and two public centers: The Urban Indian Center, a primary care center run by the Nebraska Urban Indian Health Coalition, and the People’s Health Center, a federally qualified health center (Medicare fee-for-service). Principal collaborators in creating the center were the Lincoln Lancaster Health Department, local hospitals, the University of Nebraska Dental School, the Lincoln Medical Education Program/Family Practice Residency Program, and community mental health centers.

The EDs eventually received a $300,000 grant from the Community Health Endowment. That money was used to cover the labor costs of the case managers for three years, says Libby Raetz, RN, the ED director at St. Elizabeth. Each ED campus has an RN case manager and a social services case manager. "Each of the hospitals contributed in-kind services: ED management, oversight by each facility, human resources, IT [information technology], and legal," she says.

Health Insurance Portability and Accountability Act (HIPAA) representatives also were active on both campuses, adds Radenslaben. "Putting this program together involved very close communication between the two facilities," she explains. Any ED manager considering a similar program should get these departments involved early in the project, she recommends.

At Bryan, the nursing case manager had been an ED nurse prior to moving into that position. The ED nurse was very aware of the types of problems the ED faced and had a good working knowledge of the EDs involved, Radenslaben says. "The non-nurse case manager brought us the community resource background that was needed; they have made a very good team," she adds, noting that both case managers work the same shift.

The case managers put together common pathways for both facilities. (See chart of one example, a cultural pathway.) "This enabled us to quickly determine what the patients’ issues were and to treat them on a consistent basis," says Radenslaben.

The EDs also involved patient family representatives, to ensure all processes were ethical, as well as representatives from Community Health Endowment. "They agreed to be our facilitator and also helped put us in touch with several different communities who had put together programs similar to what we were thinking about, which was very helpful," says Radenslaben.

After gathering data on the highest utilizers, the team decided to open the program to any uninsured child younger than 18, and anyone 18 and older with chronic illness diagnoses, or mental health diagnoses, Raetz says.

Any patients who visit the EDs a total of three or more times in six months make the "A list," which triggers a call from one of the case managers to explain the benefits of the program (free care), how they can receive better health care, and what to do if they choose to enroll, she says. "If they do enroll, the case manager can pull up their record, see their discharge diagnoses, and they can be case managed," Raetz says. The program is completely voluntary for patients.

The ED managers have worked with physicians’ offices and social services to let them know they have this program, Radenslaben says. "When the RN case manager gets the patient in the system and puts together a plan, they then make an appointment for the patient to follow up with a primary care provider."

Raetz says one of the most positive aspects of the program is that they want the patient to present on the initial or ongoing visit to their primary care physician already packaged — "that is, they will have an RN case manager with them, they will have all their medical records with them, a list of their medical problems, and a meds sheet." So far, the case managers have been able to attend every first visit as a natural part of their workload, says Raetz. "They know the date and time, and they just make it part of their calendar," she explains.

Because the ED’s computer systems are linked by an interface that was created in-house, an enrolled patient presents a "flag" when they tell the staff they are part of Lincoln ED Connections. "When the flag comes up, you will also see the case manager’s comment field," says Raetz. "It may say something like, Being weaned off Dilaudid [hydromorphone hydrochloride], please don’t prescribe.’"

To make sure the program stays on track, an oversight council, made up of physicians, other safety net providers, the health department, and the fire department EMS, meets quarterly to review program.

While the program is only a few months old, Raetz and Radenslaben are encouraged. While they are seeing financial savings, they not ready to disclose an actual figure. "We want to have three quarters under our belt," Raetz says. "We have to make [savings] happen to show sustainability, because in three years, the funding will be gone."

"The plan would be that based on the savings from the program that the two hospitals would take over the total cost," adds Radenslaben.

It’s benefiting the ED in terms of slowing down the number of patients they’ve seen in the ED for nonemergent issues, Radenslaben says. "We believe it will have an impact on flow, as well as on unreimbursed care."

Since similar programs and foundations exist in many areas of the country, this program could be replicated by EDs, says Raetz. "If I were an administrator and I saw that if I could get 11 people corralled [into a program like this] and save $250,000, I could certainly hire a case manager and afford it," she says.


For more information on reducing unnecessary ED visits, contact:

  • Ruth Radenslaben, ED Manager, Bryan Lincoln General Hospital Medical Center, Lincoln, NE. Phone: (402) 481-5604. E-mail: ruth.radenslaben@bryanlgh.org.
  • Libby Raetz, RN, ED Director, Saint Elizabeth Regional Medical Center, 555 S. 70th St., Lincoln, NE 68510. Phone: (402) 219-7045.

For more information on community safety net programs, contact:

  • Dyad Case Management Program, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC. Phone: (800) 446-2255.
  • ED Frequent User Program, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110. Phone: (415) 206-8000.
  • Project Access, 1102 S. Hillside, Wichita, KS 67211. Phone: (316) 688-0600.