EXECUTIVE SUMMARY

The Mount Sinai Health System in New York City has opened a new urgent care center, dubbed Express Care, just 150 feet from the ED on the campus of Mount Sinai Hospital. The new center is staffed with board-certified emergency physicians and is designed to meet the unscheduled care needs of patients in the area. However, considering the proximity of the new center to the ED, it offers some unusual advantages over off-campus urgent care sites.

  • Staff at the Express Care site have access to more advanced testing and expert consults that are available from the nearby ED.
  • While the new center should serve as a safety valve for many medical practices in the region, officials anticipate that it also may serve to decompress the ED during periods of high demand.
  • Because the urgent care center is owned and operated by Mount Sinai on its hospital campus, it must meet all EMTALA requirements, although the center is treated as a specialty clinic when it comes to billing and record keeping.

One may believe that an urgent care center staffed by board-certified emergency physicians would offer both advanced capabilities and the efficiency that goes along with employing staff members who are accustomed to treating a large, diverse patient group. However, what if this urgent care site also is located on the same hospital campus as the ED and essentially shares staff with that ED? Are there additional synergies or other advantages that come with such a configuration?

The Mount Sinai Health System in New York City is in a position to find out as it has just opened such a center, dubbed Mount Sinai Express Care, a mere 150 feet from the ED at Mount Sinai Hospital on Manhattan’s Upper East Side.

It is certainly not the first time an urgent care center has opened on a hospital campus, but creating such a close working relationship with the hospital’s ED offers some interesting advantages on which the hospital system is hoping to capitalize.

“Clearly, access to unscheduled care is a challenge and a need for our patients. EDs aren’t necessarily the best resource for all patients,” observes Andy Jagoda, MD, professor and interim chair of the department of emergency medicine at the Icahn School of Medicine at Mount Sinai. “Also, I think if we look at health systems, we have our practices, and many of these practices reserve time for a few unscheduled appointments. But as systems grow, it is becoming more and more of a challenge for those unscheduled visits to be accommodated.”

Further, this center’s proximity to and close working relationship with the ED may help decompress a busy department that has limited options for expansion, explains Judah Fierstein, MD, the director of urgent care services for the department of emergency medicine at Mount Sinai and an assistant professor of emergency medicine there. “Having a location where some of the lower-acuity patients can be seen — that is one of the strategies designed to help with [ED crowding],” he says. “There are many primary care specialty practices on the main campus as well. Having a center where they can send patients after hours is really helpful to those practices.”

For instance, in just a few months of operation, the Express Care site has begun to develop a bit of a niche in providing care to geriatric patients because it happens to be co-located with a large, existing geriatrics practice, Fierstein observes. “That has us working very closely with the geriatricians, which is helpful because the patients are medically complex and we are able to take care of them in a way that I think is very helpful,” he says, noting these patients struggle to handle the busy, chaotic ED environment.

Fierstein says that the strategic, on-campus location of the center offers other benefits as well. “We are able to do any really advanced imaging studies. We can do lab tests that normally can’t be processed at the point of care at other urgent care sites,” he explains. “We can also get consulting services to come in. The consultants that cover the ED will come to Express Care, so that is something we can’t do at the other [urgent care sites].”

Further, when patients present to the on-campus Express Care site, and it is determined that their care needs are more appropriate for the ED, it is a simple matter to transition those patients to the right spot.

“There is an ED rapid-response team that will come to Express Care for [these] patients,” Fierstein says. “We have worked out pathways for managing acute MI [myocardial infarction] and stroke patients that might present to Express Care. Some of those pathways actually bypass the ED, and those patients will go directly from Express Care to the catheterization lab [at the hospital].”

In fact, the Express Care staff practice mock stroke codes so everyone will know what the procedure is in such time-sensitive cases, Fierstein explains.

Jagoda adds that because the urgent care center is owned and operated by the Mount Sinai Hospital on its campus, the center must meet all Emergency Medical Treatment and Labor Act (EMTALA) requirements, just like the ED and any other specialty clinic that is located on the hospital campus. This means all patients presenting to the urgent care center receive a screening exam and must be deemed stable before they can transfer to any other care setting, Jagoda says.

However, as far as billing is concerned, the urgent care center is not operated as an extension of the ED.

“It is not directly adjacent to the ED; therefore, it stands alone,” Jagoda says. “The electronic medical record, the record keeping, and billing are all done as if [the urgent care center] is a specialty clinic.”

Facilitate Transitions

While there will always be some patients who present to the wrong site for care, working in such close proximity to the ED makes a difference, Fierstein says. “When we get patients who are inappropriately coming to an urgent care center that is off campus, it is a lot harder [to make the transition],” he says. “First of all, we need to convince them to go to the hospital, which is sometimes very difficult. Secondly, there is a real delay in care [because] we have to wait for an ambulance to arrive.”

Jagoda estimates that 3% to 5% of patients who present to an urgent care site are transitioned to the ED after they have been assessed. Often, this is because a patient is found to have a condition that is potentially serious and in need of more in-depth testing or observation and treatment.

“Our patients are aging, they have multiple medical problems, and they are extremely complex,” Jagoda says. “That is one of the challenges of healthcare delivery across the country and one of the big challenges for urgent care centers in big urban areas and even in smaller areas — the complexity of the patients who are showing up.”

For example, Jagoda notes that an elderly patient who has been coughing for three or more days and perhaps running a fever as well might present to an urgent care center because he or she is worried about possible bronchitis. However, when the patient is seen, his or her vital signs are out of the normal range, and the patient appears to have some difficulty breathing. “This is a patient who is going to be in need of a fair amount of assessment and probably treatment that is beyond what the [urgent care center] is going to be able to do,” Jagoda notes.

Educate Patients

The Express Care center on the Mount Sinai Hospital campus is, in fact, the second urgent care center that the health system has opened close to one of its hospitals, Jagoda observes.

“The first one that we opened is at our Mount Sinai Beth Israel campus, which is in downtown Manhattan,” he says. “The difference between these two centers is that the one uptown at Mount Sinai Hospital is in close proximity and at street level to the ED. Therefore, patients walking in front of the hospital will see an ‘Express Care’ sign and will also see an ‘ED’ sign.”

However, the downtown urgent care site is several blocks from the hospital’s ED, and it is located on the second floor of an ambulatory building. The access is not quite the same, Jagoda observes.

Still, at both sites, it is up to patients to determine where their healthcare needs will be met best. “When patients present to the ED, they are evaluated. They are not screened and then re-triaged to Express Care or to an ambulatory setting,” explains Jagoda, noting that this is the case even if a determination could be made that a patient might be served best in an internal medicine clinic. “A patient who presents gets seen and treated.”

This is the case even though EMTALA requires only that a screening exam for stability be performed, Jagoda adds. “Theoretically, if a patient is screened and stable, he could be re-triaged to another area, but there are very few EDs that will follow that model,” he says.

The key, then, is education so that patients understand the capabilities of the ED vs. an urgent care setting. Much of this education is conducted through promotion. “All of our advertising tries to educate patients about what is appropriate for urgent care. Our website talks about what we take care of and what carve-outs should be for emergency care,” Fierstein says. “[In addition,] when patients are discharged from the ED, they all leave with education about the Express Care option and what might be appropriate for that [setting].”

Physicians in the region also are learning about the capabilities of the Express Care site, although Jagoda reiterates that it is the patients themselves who determine where they access care.

Mount Sinai is staffing its urgent care centers with emergency physicians, even though this type of personnel is in very short supply across the country. Staffing in this way is a challenge, Jagoda acknowledges, but he says that quality and efficiency are the big drivers of the decision. “Emergency physicians have a broad scope of practice. They are trained in managing all ages, and they have training in recognizing very sick patients who might not appear to be very sick,” he explains. “Therefore, in the long run, they tend to be quite efficient at healthcare resource utilization. But in addition, because of [their] training, [they] are very efficient in multitasking and managing a large number of patients at the same time.”

For instance, Jagoda notes that whether there is an orthopedic problem that requires splinting or casting, a surgical problem that requires a minor surgical intervention, or a pediatric problem that is either medical or surgical, these are all within the capabilities of emergency providers.

Fierstein agrees, but also notes that the acuity level of patients who present to the on-campus urgent care center is more in line with the expertise of emergency providers. “This [urgent care] center is really run by the ED and shares staff with the ED,” he says. However, Fierstein adds that it is generally very difficult to recruit emergency providers. “The ED [at Mount Sinai Hospital] has a number of open positions. I am sure that every ED in New York City is just the same.”

With the new Express Care site only open for a few months, it is not yet clear how it will affect ED crowding. Fierstein says that about half of the patients seen at the Express Care site say they would otherwise have gone to the ED for their care needs.

Another question yet to be answered is whether the Express Care site will make a dent in the number of unscheduled walk-in patients at the hospital’s ambulatory clinic sites, although administrators are hopeful on that point.

“The other day our pediatric clinic was overwhelmed with walk-in patients. They asked if they could start sending patients over to the Express Care site. There is a little bit of a safety-valve function, but really there is a certain amount of balance that is going to have to be carefully assessed so that no one component of ambulatory services gets overwhelmed,” Jagoda says.

Further, Jagoda anticipates that the Express Care site also will provide a safety valve for the ED during periods of high use, such as during virulent flu seasons.

“We saw that last year across the country, EDs were overwhelmed with the amount of influenza, and [urgent care] served as an alternate site to provide that care,” he says.

SOURCES

  • Judah Fierstein, MD, Director, Urgent Care Services; Assistant Professor, Department of Emergency Medicine, Icahn School of Medicine, Mount Sinai, New York. Email: judah.fierstein@mssm.edu.
  • Andy Jagoda, MD, Professor and Interim Chair, Department of Emergency Medicine, Icahn School of Medicine, Mount Sinai, New York. Email: andy.jagoda@mountsinai.org.