ED care program has better outcomes

Relies on Consistent Care Program

An emergency department (ED) program has helped reduce ED visits and has resulted in health care savings through targeting services to emergency department frequent fliers.

Patients enrolled in the program often have multiple health problems, including mental illness, chemical dependency, and other chronic diseases. Although these patients need continual monitoring and care, they often lack consistent primary care services when they are discharged from the hospital.

Providence St. Peter Hospital in Olympia, WA, has developed a successful program targeting these patients. Called the Consistent Care Program, it enrolls patients in a five-county region. The program collaborates with a non-profit coalition of rural and urban hospitals, providers, public health clinics, and community health centers.

"Not surprisingly, the large part of this population is inappropriately seeking medication, narcotics, analgesics, and they don't have a proper primary care provider relationship," says Joe Pellicer, MD, medical director of the emergency department at Providence St. Peter Hospital.

Physicians, physician assistants, and nurse practitioners give letters of introduction about the program to patients who have repeatedly used the emergency department as their primary health care option.

One of the letters might say, "You've been here five times in the past month, and we have a program that will help you establish a relationship with a single primary care provider. In exchange for that, we expect you will not keep coming back to the emergency department," Pellicer says.

"They're given the letter and they can sign that voluntarily or choose not to, as is sometimes the case," he says.

"If they choose not to, then we send them a letter that says we're sorry they have chosen not to accept our invitation," he adds. "But here is the deal: 'You are in the program based on your history, and a care plan will be written. You will not receive controlled substances unless there's a new emergency on top of your underlying condition.'"

The program includes an important monthly meeting for the physician in charge, a nurse coordinator, representatives from the local clinic, and sometimes representatives from the court system and mental health care system.

"I go to these meetings, as well," Pellicer says. "Between us there usually is somebody who knows this patient pretty well."

The meetings are an opportunity to share information about patients, who are told about these conferences in their letters.

"Their names are highlighted in our system," Pellicer says. "With a single click, the physician who sees them can bring up the care plan."

The electronic information might say that the patient is being seen at a particular primary care clinic and ask that the physician inform the patient that he or she must go to that clinic for pain medication.

"Many of these patients have chronic medical issues and chronic pain issues," he explains. "They are using the emergency department inappropriately; they want to be seen at 11 p.m. and can't be bothered with schedules and seeing someone in the daytime."

With the new program, ED clinicians will medically screen these patients, but they won't prescribe pain medication for chronic concerns. So if a patient has chest pain, he or she will be treated for chest pain. But the program's electronic red flag might note that the patient has been to the ED 10 times previously, always reporting chest pain, he says.

Physicians are trained to tell these patients that they won't be prescribing pain medication tonight, and patients will need to return to their assigned primary care providers. If the patient who typically complains of chest or back pain now has a broken arm, then the physician could prescribe a painkiller, but each case is a judgment call.

"There are a few famous examples of people with hundreds of ED visits — making it a full-time occupation of going from hospital to hospital, and no one is communicating," Pellicer adds. "We feel through a documentable system of establishing care with a primary care source, we can legitimately say, 'No, we're not doing this; these are chronic concerns, and you have a place to go that will address these concerns. This is not an emergency tonight.'"

The program has enrolled about 600 people and recently won a national award for safety and quality, called the NOVA Award. The American Hospital Association gives the award to hospitals that develop collaborative efforts to improve community health.

Since the program was begun in 2003, there have been a number of benefits, including cost savings, preserving ED beds for patients who are in greater need of emergency services, fewer clinician resources going toward frequent-flier patients who should have been seen at a primary care clinic, and better communication between hospital staff and community providers.

The program includes a patient care coordinator, who is a nurse who communicates with patients and makes sure they have a primary care provider. The patient care coordinator also helps with transitioning ED patients to the community through established communication and relationships with community psychiatric services, parole services, and holding monthly meetings with community providers.

"Patient care coordinators can pull up patients' visits and history for the past month and review their treatment options," Pellicer says. "They can contact patients and make a game plan to address inappropriate behavior."

While this program was designed specifically for the population who uses the ED for primary care and pain medication needs, it can be adapted for use with other chronic disease populations, Pellicer notes.