EXECUTIVE SUMMARY
A novel program at Sinai Hospital of Baltimore avoided charges of more than $200,000 by addressing the needs of frequent emergency department (ED) users. Registrars take these steps:
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Alert care coordinator immediately if a patient has been to the ED recently.
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Look for icons indicating the patient came to the ED in the previous 30 days.
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Scan the census, and watch for familiar names.
Do you assume that “superusers” of the emergency department (ED), or individuals who present very frequently with the same vague complaints, are just a nuisance?
This assumption is incorrect and dangerous, according to recent research. Patients who present to EDs frequently are more than twice as likely as infrequent users to die, be hospitalized, or require other outpatient treatment, according to a recent analysis of 31 studies.1
“We feel strongly that our results highlight a need to regard frequent ED users as a high-risk patient population in the ED,” says Jessica Moe, MD, the study’s lead author and a resident in the Department of Emergency Medicine at University of Alberta in Edmonton, Canada.
Up to one in 12 ED patients is a frequent user, according to the studies analyzed by the researchers, which defined frequent users as visiting from four up to 20 times a year. “The first step in exploring potential interventions to address frequent ED use is to identify the scope of the issue,” says Moe. All members of the extended healthcare team, including patient access, can play an important role in identifying high-use ED patients, she adds. Moe suggests these strategies:
• Implement flagging systems into existing registration processes.
“This could allow patient access and registration staff to alert physician and key non-physician healthcare professionals, such as social workers or psychologists, about unusually frequent visit patterns,” says Moe.
• Implement notification systems initiated at registration to alert key members of the healthcare team when target patients arrive.
“This could facilitate easy access to shared, pre-determined care strategies,” says Moe.
REGISTRARS PLAY KEY ROLE
When ED registrars at Sinai Hospital of Baltimore (MD) see that a patient has been to the ED recently, they let care coordinators know immediately.
“There may be concerns that can be addressed before they see a doctor or a nurse,” says Kathy Salamone, interim director of patient access.
Care coordinators, stationed in the ED, connect “superusers” to primary care and other resources. Olympia Ross, lead care manager in the ED, says, “We set up some specific criteria as a guide for determining who would be eligible.”
Three categories of patients are referred:
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“low-risk,” which includes patients without insurance;
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“at-risk” patients, which includes patients who presented three or more times in the previous four months, pregnant women without prenatal care, patients without primary care providers, patients with unmanaged chronic diseases, patients who are non-compliant with medications, and patients who lack transportation;
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“super utilizers,” who are patients who presented to the ED 10 or more times in the previous four months.
“The patient access team is very good at identifying the super utilizers,” Ross says. “They are very well-known to us.” Registrars call care coordinators to say, “Mrs. Jones is here again. Maybe you can meet her in triage.”
At first, providers relied strictly on icons in the hospital’s electronic medical record that alerted them if a patient had been an inpatient admission within the previous 30 days. However, these icons weren’t capturing patients who had come to the ED but weren’t admitted. A new icon was created, for patients who had come to the ED in the previous 30 days.
“Registrars have access to the same screen and can see the icons as well,” says Ross. “They are our first-line defense.”
Registrars scan the patient census and watch for familiar names. “We sometimes see them before the provider will,” Ross says. “Providers know these patients like the back of their hands but may not have seen them come in.”
FEWER BARRIERS TO ACCESS
The average charge for an ED visit is $1,100.
“We estimate that we avoided ED charges of over $200,000 in the past year, which is a pretty huge savings,” says Ross.
The ultimate goal is that people have fewer barriers to accessing healthcare. “We find that in our community, there are, unfortunately, a lot of barriers,” says Ross. The vast majority of patients seen repeatedly in the ED for non-emergency needs have no primary care provider, and they have knowledge deficits about how to manage chronic medical problems.
“We see a lot of patients who are simply not connected to appropriate resources or the necessary healthcare providers to meet their needs,” says Ross. One patient came to the ED five times in a single month and reported severe depression. A care coordinator connected him to primary and mental health care. “This patient has not been back to the ED since he was referred to the program,” says Ross.
Care coordinators sometimes find out that patients are coming to the ED because of poor access to the basic needs of life. One 54-year-old man came to the ED three times in five days. “The care coordinator learned that in addition to having a hernia and no insurance, he frequently went hungry,” Ross says.
The care coordinator did three home visits over the next few weeks and determined that the man was eligible for Medicaid and food stamps. “When his Medicaid number came through, he got hernia surgery scheduled and has not visited the ED since,” Ross says.
REFERENCE
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Moe J, Kirkland S, Ospina MB, et al. Mortality, admission rates and outpatient use among frequent users of emergency departments: A systematic review. Emerg Med J 2015; doi: 10.1136/emermed-2014-204496.
SOURCES
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Jessica Moe, MD, Department of Emergency Medicine, University of Alberta in Edmonton, Canada. Email: [email protected].
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Olympia Ross, MSN, RN, ACM, Lead Care Manager, Emergency Department, Sinai Hospital of Baltimore (MD). Phone: (410) 601-9356. Fax: (410) 601-4232. Email: [email protected].
