Frequent ED users often are frustrating for emergency providers, particularly when patients with serious underlying needs are not addressed. Such patients may visit the ED every week or even more frequently, and yet they rarely present with a medical emergency, and there may be little a busy emergency clinician can do to help. In addition to increasing healthcare costs, the people on both ends of such encounters may feel dissatisfied or discouraged.

However, a new program at Grady Memorial Hospital in Atlanta seeks to short-circuit this cycle of care so that patients with complex conditions are connected with the help they need without continually sapping emergency medicine resources. Called the Chronic Care Clinic (CCC), the program is just getting started, but early results show promise. Grady is set to expand the program in coming months.

Like many large, urban medical centers, the ED at Grady Hospital sees a large number of frequent users, but their motivations in seeking emergency care often are misjudged, explains Hany Atallah, MD, the chief of emergency medicine in the Grady Health System and medical director of the Emergency Care Center. “Many of these patients have chronic medical conditions and are concerned about what is going on with their health, which is why they come in frequently. They often have a feeling there is an emergency and want to make sure nothing bad is happening.”

The CCC was developed with frequent users in mind so that these patients who present with issues that are not commonly considered emergencies can develop a relationship with a primary care provider (PCP) who can better oversee the trajectory of their care. “The literature shows that you can save a lot of money by doing this, and you actually end up providing better care, which is really what we want,” Atallah says.

To get the CCC started, in February 2017 administrators analyzed hospital data to identify frequent ED users, Atallah notes.

“We wanted to start with success, so we began by enrolling patients who had actually shown a record of having shown up to clinic appointments in the past,” he says. “Maybe they didn’t have perfect attendance to these appointments, but we wanted people who were familiar with the clinic system and had used the clinic before so that we could basically reintroduce that to them.”

The process of identifying appropriate patients for the program has now morphed into an “ER Frequenter Registry,” explains Kelley Carroll, MD, vice president and chief of ambulatory medicine in the Grady Health System. “The initial definition for inclusion in the registry was 12 ED visits in 12 months, and that produced a registry of about 600 patients.”

However, most of these patients were directed to a specialty behavioral health clinic or to substance abuse counseling, and administrators experienced difficulty connecting with another 30% of these patients. “Either they did not show up for their first visit [to the CCC] or we just could not connect with them,” Carroll notes.

A third group of patients either left without seeing anyone or didn’t present with any clinical information to determine whether they needed to be contacted. Consequently, the criteria for enrollment in the CCC have been modified to include patients who have visited the ED six times in six months, Carroll explains.

“Currently enrolled right now, we have 41 patients,” she says.

Patient navigators on site in the ED are charged with intervening with frequent users when they present for care. “[Navigators] will keep an eye on the track board and look for when a patient’s name pops up,” Atallah explains. “We have a little box that identifies the patient as a frequent utilizer of emergency services, so when they see that box checked, it is an easy way for them to look through all the patients we have and quickly identify [the high users].”

When a high-use patient is flagged, a patient navigator will take steps to expedite that patient through the ED process, and then make sure that patient is directed to the CCC. In the early days of the program, these patients were directed to a walk-in clinic that is just a stone’s throw from the ED, Atallah notes. However, Grady is in the process of moving the CCC to a separate space on campus called the Transition of Care Clinic.

“It is still on our main campus, but it is on the outpatient clinic side of the building,” Carroll explains. “The Transition of Care Clinic is seeing post-discharge and post-ED visit patients, and it is also handling quick follow-up for patients who are at high risk for readmissions.”

When the move to the new space is complete, the CCC essentially will operate under the umbrella of the larger Transition of Care Clinic and share some of the clinical staff with other programs housed there, but it will employ its own community health worker, RN, and advanced practice practitioner.

Frequent users who present for care to the ED receive same-day appointments in the CCC to facilitate the transition. The idea is for the patients to realize that every time they come to the ED they are sent to the CCC, so they might as well just visit the CCC to begin with, Atallah says.

Prepare for Social Needs

Thus far, no patterns have emerged in terms of top diagnoses among high-use patients, but administrators have found that social limitations rather than chronic diseases have been the primary driver behind these patients’ frequent ED use.

“Most of them need transportation; a good percentage of them — about 30% — require housing; and 16 out of the 41 have needed linkages to family resources,” Carroll shares. “Really, [the biggest needs] have been for social interventions more than titration of medicines or management of chronic diseases.”

Navigators work with community health workers to link patients with the resources those patients require. “Those are the people on the ground really making it happen for the patient,” Carroll says. “We do have a social worker, and we have an RN care resource manager who acts as a sort of pilot ... for the social needs of the patient.”

For instance, community health workers might visit patients in their homes to find out what barriers may be keeping them from following their plan of care or preventing them from making it to scheduled clinic appointments, resulting instead in ED visits, Carroll notes. In other cases, the community health workers may walk appropriate patients to financial services to get them signed up for Medicaid.

“These patients have difficulty navigating the medical system, so the easiest thing for them to do is walk into the ED. It is hard for them to understand how to pick up the phone and call for a cardiology appointment, figure out how to get Medicaid, or how to get their Medicare part B coverage,” Carroll explains. “They don’t have self-management skills, so the navigator and the community health worker are teaching them those skills along with the RN.”

Pharmacists are part of the CCC team, too, Atallah adds. “These patients have a hard time understanding their health and what needs to happen,” he says. “You really have to very much hold their hands through the whole process until they learn to really start doing these things themselves.”

One other resource that is at the disposal of the CCC program is Mobile Integrated Health (MIH), a paramedicine program in the Grady Health System that also helps break down barriers to care for high-needs patients who frequent the ED. An MIH team consists of a nurse practitioner and a paramedic who can visit a patient’s home and address any challenges he or she may face.

“Once the CCC establishes someone as a patient, it might send a referral to MIH to conduct a home evaluation,” explains Michael Colman, MPA, NRP, vice president of EMS Mobile Advanced Practice at Grady Health System. “When a patient is in the doctor’s office, it might seem like everything is OK, but when [patients] get home, they might have no food and no heat. They might be living in an abandoned building. The nurse practitioner and the paramedic can go out to the residence and give the providers some insight [on their patients] they don’t have to try and help set up some strategies so that the patient receives better care.”

The MIH team may review a patient’s prescriptions, and give the patient an opportunity to ask questions in a non-intimidating, non-rushed kind of environment.

“We have more time [than a typical doctor’s visit] ... and we can come back the next day,” Colman notes. In the early days of the program, the MIH team would visit patients prior to their first CCC appointment, but team members found it was more effective to see patients afterward because not every patient requires a home visit, observes Matthew Thornton, EMT-P, the district supervisor for Grady EMS MIH. “A lot of the patients we go to see have been enrolled [in the CCC], but then miss their appointments, so we get a referral and go out there and see what is wrong,” he says.

Thornton notes that the types of patients he encounters from the CCC run the gamut.

“We have patients in their 70s and 80s with heart failure and COPD who come to the ED all the time, and we have patients in their 20s who have trouble with their diabetes,” he says.

Careful With Transitions

When patients can manage their required healthcare tasks on their own, CCC staff members take steps to bridge these patients from the CCC to primary care.

“So far, we have had eight patients we have transitioned into primary care, and we have learned a lot from that experience,” Carroll says. “A few of the patients have bounced back [to the CCC] because the primary care [office] didn’t have the same wraparound services with all these ancillary providers around them, so that is one lesson learned.”

To correct this deficit, Grady is working to build such services around primary care. “We will probably need a navigator and a community health worker to actually stay with the patients or at least check in with them for at least a month after transitioning them to make sure they are sticking with primary care,” Carroll explains. Despite this issue, the program is working as intended. The cohort of 41 patients enrolled in the program logged 185 ED visits per quarter prior to enrollment in the CCC program.

“Post-enrollment, they now have 84 visits per quarter, so it is saving 100 visits per quarter for that cohort,” Carroll notes. “Looking at utilization, we have 65% fewer ED visits, 17% fewer inpatient admissions, and 146% more outpatient or ambulatory visits, and their monthly costs have declined by 50%.”

Encouraged by the data, administrators plan to expand the program further in 2018.

“We will be able to enroll more patients because we will have more staff as part of the Transition [of] Care Clinic,” Carroll notes. “We will have a behavioral health professional there full time and two full-time PharmDs, so we will be able to see some of the patients who have been deemed inappropriate [for the program thus far] because their primary diagnosis was substance abuse.”

That should be a big help because roughly 50% of the ER Frequenter Registry in 2017 were patients with a primary diagnosis of substance abuse, but the CCC did not have the infrastructure in place to manage those patients. “We did have a substance abuse counselor in the ED who would try a brief intervention with the patient, and then bridge them [to treatment], but most of those patients did not follow up,” Carroll explains. “We will now have more staff concentrated on that patient population.”

Atallah’s advice to other EDs that face similar challenges in meeting the needs of frequent users is to start small initially and set up the organization for success. “Troubleshoot with patients with whom you are likely to be successful. That was a big help for us,” he says. “Also, you can never plan enough. Understand all the moving parts that you are going to need to make the program work.”

Further, Carroll advises organizations to remember the need to hire intensive social and family experts.

“We have a social worker who seems to magically do a good job of finding places for people to live,” she says. “Pay attention to the social aspects because the reason these people come to the ED frequently is very important.”