ED diversion: Multi-disciplinary approach engages high utilizers, helps them better navigate the health care system

Collaborative model pairs high-risk patients with community health workers

Like many EDs across the country, the ED at St. Charles Medical Center in Bend, OR, sees its share of patients with urgent or primary care needs, and many of these patients frequent the ED 10 or more times a year. It's a problem because not only does the hospital lose money on a significant percentage of these patients, but the truth is most of these individuals could be receiving better care in a more appropriate setting, explains Robin Henderson, PsyD, the director of behavioral health services in the St. Charles Health System.

However, getting frequent ED users to change their health care habits is often anything but easy. Many of them have complex social and behavioral health needs in addition to medical problems. Nonetheless, the St. Charles Health System is beginning to make headway with this patient group through a new program that routinely identifies frequent ED users and develops interventions designed to address their needs more appropriately. In some cases, these individuals are being paired with community health workers who then help them to better navigate the health care system.

The approach has reduced the inappropriate use of the ED by 45% to 70% in the cohorts of patients that the health system has analyzed thus far, says Henderson, and she expects the health system to make further progress. "When we first started the program, we identified people who were visiting the ED 50 and 60 times a year. It was absolutely remarkable," she says. "What we are trying to do is get to the point where that never happens again."

Identify high utilizers

The ED diversion project is just one of many initiatives that is flowing from a health care collaborative that includes the Medicaid payer and federally qualified health clinics in the region, the St. Charles Health System that either owns or manages all four hospitals that serve the area, and Health Matters of Central Oregon, a non-profit group in Bend, OR, that contracts with the other collaborative members to provide them with community health workers.

All of these entities came together in response to a mandate from the Oregon legislature in 2009 to look at ways to create a single point of accountability for health care dollars flowing into the region, as well as to engage in initiatives that would reduce the overall cost of health care, explains Henderson. "In our early meetings, we really wanted to come up with projects that could deliver a big win quickly, and one of the problems that we all knew we had was the problem of high-frequency utilizers of the ED," she says. "We ran an initial report 18 months ago and identified about 600 patients who had visited the ED 13 or more times in a year. We decided that was the group we wanted to address."

When the ED diversion program first went live in the last quarter of 2010, investigators focused on high ED utilizers over the previous year, but the program has since been tweaked to look more closely at quarterly trends, explains Henderson. "We may look at someone who has had four ED visits in the last quarter and decide we need to engage that person," she says. "We know that ED use can be very cyclical and we have seen that as this program as played out over the last year."

Each hospital has a multidisciplinary engagement team comprised of one or more ED physicians, a nurse case manager for the ED, a social worker, a behavioral health consultant who specializes in primary care intervention, and, sometimes, a community health worker will be part of this team as well, says Henderson. These teams then meet weekly or bi-weekly to review the health records of each identified high-utilizing patient to evaluate why this person keeps coming back to the ED for care.

"Some patients are coming in continuously with chronic pain issues because they are not integrated into primary care," says Henderson, noting that other patients may have transportation issues, mental health problems, or other barriers that keep them from accessing primary care in a more appropriate setting. Whatever the issues are, the engagement team will use all of the information it has to develop a care plan designed to help that patient receive the best care in the most appropriate setting.

In many cases, the barriers or issues that prompt patients to use the ED inappropriately can be resolved by connecting the patient with a behavioral health specialist or a social worker. However, a select number of the higher-risk patients will be paired with a community health worker who will then provide one-on-one guidance and support to these individuals to help them work through their often complex medical and social issues.

Link high-risk patients with a health advocate

Health Matters of Central Oregon is involved with a number of health care initiatives, but one of its responsibilities is to hire and train community health workers for the ED diversion project. "These are paraprofessionals. They're not leading the [engagement] team, they're there to support the team," explains Alisha Fehrenbacher, MHA, MGA, the chief executive officer of Health Matters. "The providers give guidance to community health workers so that they can help patients navigate the system."

The community health workers follow a structured format that is based on the Pathways Community Health Access Project (CHAP) model that was developed by Mark Redding, MD, and Sarah Redding, MD, in Mansfield, OH. The model identifies specific pathways or intervention strategies to follow based on patient conditions. However, in all cases the role of the community health worker is to build a rapport with patients and to act as their advocate, adds Fehrenbacher.

Health Matters recruits community health workers from the area being served and then trains them through a class that is now embedded at a local community college, says Fehrenbacher. "It's an opportunity to help with navigation, health care costs, and satisfaction with the system … and it is also workforce development, so we are trying to build this workforce to help augment and assist with delivery system reform," she says.

While the approach was initially funded through grants, the St. Charles Health System now pays for two community health workers to work with the ED diversion project, and it will soon bring on a third. One of these individuals, Becky Wilkinson, works out of an office at St. Charles Medical Center.

"Most of the patients who are frequent users of the ED are not always easy to get a hold of. There are times when I call them or go to their homes to try to engage them, but I have found it is more successful for me to catch them when they are in the ED," says Wilkinson. "I will either see them on the bed board because I know their names or I will get called by a member of the ED staff."

Keep the focus on barriers

Typically, when Wilkinson is notified that a high-utilizing patient is in the ED, she will immediately go to the ED to meet with the patient and explain the program. Very few patients are resistant to being involved, says Wilkinson, noting that she tells patients that her role is to be an advocate for them. "I have patient-clients who have severe behavioral health issues or are developmentally delayed, but I also have patients who just need some life skills," she says.

The way the model works, there are more than 80 pathways, each representing some sort of barrier, adds Wilkinson, noting that common barriers involve transportation, housing, or lack of phone service, and there are many combinations of barriers. The community health worker's job is to work with the patient toward resolving each barrier.

For example, Wilkinson explains that she has just begun working with a woman who has been coming into the ED frequently with chronic back pain problems as well as several behavioral health issues. "I learned that this patient does have a primary care home, but she has not been able to access it. She could not get an appointment, and felt that they were just not available to her, so she was coming to the ED for care," explains Wilkinson.

Wilkinson enrolled the patient in the program, and provided her with education about the type of care she would be able to receive in a primary care setting. "I said I would make an appointment for her with her primary care doctor and go with her to the appointment so that we could try to coordinate her care and get her in to see a shoulder specialist," says Wilkinson. "A lot of times, patients are so overwhelmed with all of their personal issues and mental health issues that they just don't seem to be good advocates for themselves, so I will sit down with this patient before the appointment and we will work out some goals for the visit."

Wilkinson says she always asks patients if they want her to speak with the provider or if they would prefer for her just to observe. "Most of the time, I help them explain to the doctor what is going on and then we discuss how we can coordinate care for the next step in their chronic issue," she says.

Get patients established in medical homes

Having someone who will act as a health advocate is what makes the critical difference to many of these high-utilizing patients, says Henderson. "What we find with a lot of the people who use the ED frequently is that they are comfortable there. These are the people who care for them. It is, in essence, their medical home," she says. "So what Becky [Wilkinson] and the other community health workers do is facilitate the transfer of the medical home from the ED to a [more appropriate setting], whether that is a safety-net clinic, a primary care clinic, or wherever that patient wishes to engage." (Also see Management Tip: Multidisciplinary approach key to helping patients access care appropriately, below.)

Many of these patients just need assistance in navigating the health care system, adds Henderson. "What used to happen is people would walk out of the ED with a sheet of instructions that would say to call their primary care provider," she says. However, many individuals would fall through the cracks for any number of reasons. Maybe the patients were no longer welcome at their primary medical home because they had missed too many appointments, they had some type of mental health issue that was getting in the way, or they lacked transportation or childcare, she says.

"Now, whatever the issue is, the community health workers figure it out and attempt to renegotiate that relationship," says Henderson. "What we see happening time and time again is that once people are established with their primary medical home, they don't need the ED to fulfill that role anymore."

Another benefit to the program is that ED providers and registration personnel are highly satisfied with having a resource than can help them manage patients who keep returning to the ED for care. "Most of my patient-clients have been to the ED so many times that it is frustrating for the physicians, especially because they feel that they can't help them and that they are not fixing the problem," says Wilkinson. "They don't know what else to do with these patients, so I am constantly getting thanked [for stepping in to help these patients]."

Wilkinson observes that area clinics have also come to rely on her knowledge of these patients when they are making care decisions. "I know more about these individuals than they are going to tell their doctors, so it is easy for the physicians or the clinics to call me and ask my opinion about what would work best to help keep a patient on track," she says.

Wilkinson, who has been a community health worker since January 2011, is currently working with about 60 patient-clients, but she acknowledges that some of them just need help getting connected with a primary care home, while others need more active engagement over a period of time. "What I have found is that there are definitely peaks and valleys ... but I always stay in touch [with patient-clients] and make sure that they are following up with their specialty visits or whatever they need to do," she says.

The ED diversion model offers some financial appeal to St. Charles Medical Center because the ED there actually loses money on Medicaid patients, and the vast majority of patients who are identified for the program are on Medicaid, says Henderson. However, that benefit does not carry over to the other three hospitals that are involved in the program.

"This is a conscious choice we have all made because it is the right thing to do for our patients," says Henderson. However, the financial case for the model may become more compelling if Oregon takes similar steps to its neighbor, the state of Washington, which has put hospitals on notice that it will only cover three non-emergency ED visits by Medicaid recipients. Washington lawmakers expect to save $34 million a year through the move, which went into effect October 1, 2011.

In any event, Henderson stresses that the approach fits in well with the move toward accountable care organizations. "We have to figure out how to engage people more with their health care in the medical home model. That is where health care is going, and we have to prepare ourselves for a new way of getting reimbursed."


Management Tip

Multidisciplinary approach is key to helping patients access care appropriately

If you want to have success in directing frequent ED utilizers to more appropriate settings of care, you have to look beyond their clinical needs, stresses Robin Henderson, PsyD, the director of behavioral health services for the St. Charles Health System in Bend, OR, a group that has implemented an ED diversion project that is successfully reducing inappropriate ED utilization. "You have to recognize more than just the physical body that walks into your ED," she says. "When someone has chronic pain, it impacts them emotionally, it impacts their family life, and it impacts their ability to work."

Henderson advises colleagues to tackle this issue with a multidisciplinary approach that considers all barriers and prioritizes care coordination. "What it comes down to is meeting a patient where they are, and that is what care coordination is," she says.