By Melinda Young


A study showed frequent ED visitors experience higher death rates and more social determinants of health issues — problems that can be reduced through better care coordination and communication.

People who often end up in the ED are more likely to be homeless and experience substance use disorders, mental health problems, and social issues, such as having been jailed.

A case management-style team can work with ED patients to address their social determinants of health needs and ensure transition to community healthcare providers.

An ED transition program also can include a pharmacist to help vulnerable ED patients fill prescriptions when they are discharged.

Health systems that employ care coordination/case management teams in the ED can save hundreds of thousands of dollars, and improve the health of some of their most vulnerable patients.

The results of a recent study showed that frequent ED users experience higher death rates and greater health-related social needs. One solution is care coordination and communication.1

“Right now, there is a large emphasis by policymakers and clinicians on patients who use emergency departments frequently,” says Hemal Kanzaria, MD, MSc, associate professor in the department of emergency medicine and an affiliated faculty member at the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Kanzaria is the lead author on a paper about frequent ED users.

“In our study, we found that frequent emergency department use had higher use of all nonemergency medical services,” he says. These include increased use of primary care providers, urgent care, behavioral health services, and a sobering center.

The study revealed that 22% of people who did not use the ED frequently had logged mental health visits within the previous year. For frequent ED users, 46% recorded mental health visits, and for people who used the ED the most, two-thirds had used mental health services.1

Substance use followed a similar pattern: About 8% of non-ED users had a substance use disorder visit, 28% of frequent ED users had a substance use disorder visit, and 54% of the super frequent ED users had a substance use disorder visit.1

Frequent ED users also were more likely to be homeless, have been jailed, and have high social needs. The most frequent ED users experienced tri-morbidity, including mental health, substance use, and medical comorbidities.1

“These patients are very sick and seeking care for medical needs. But they also are coming in to the ED for social and behavioral health needs, and they come to the emergency department a lot,” Kanzaria says. “That should make us think about how we’re organizing our system of care to meet their needs.”

Traditionally, EDs are set up to take care of patients with medical emergencies, such as traumatic injuries, heart attacks, and strokes. The study’s findings suggest that EDs should be adapted to address the new realities of their most frequent patients.

“We have to think about how we can best address and partner to address their social needs and behavioral health needs,” Kanzaria says.

One method involves a case management-style team approach to ED navigation. Nurses, social workers, case managers, and others can work together to address the social determinants of health and care transitions of ED patients who need sociobehavioral health services, says Julie Nevers, MN, BSN, CCM, director of care coordination at St. Tammany Health System in Covington, LA.

“We identified a need to have a team approach for emergency department navigation,” Nevers says. “This is to involve the RN in case management, the social worker to focus on social determinants of health, and the psychosocial aspect of navigation.”

The team also includes a utilization management person and an ED navigator. The team uses data and a dashboard to help identify at-risk patients. (See story on team and identifying patients in this issue.)

“Having the team in the emergency department has really proved to be beneficial to us,” Nevers adds. “The ED team decides if we can avoid an admission and get patients the services they need within our market community, instead of putting them in a bed and potentially admitting them to the facility for low-level care.”

Kanzaria works with a hospital that uses a social medicine ED program to meet patients’ social and medical needs. The program consists of social workers, a care coordinator, a quality improvement specialist, and Kanzaria. The program also includes a pharmacist who ensures vulnerable ED patients, including patients with addiction or mental health problems, fill their prescriptions when they are discharged.

“This is so they don’t have to take all of their life belongings on two buses and pay out of pocket to pick up their medication,” Kanzaria says. “We give patients their medication free of charge.”

One component of the program engages patients with medication-assisted therapy. Another includes case management that starts in the ED and follows patients for six months in the outpatient setting. “We partner with other groups of people who are experts on housing,” he adds.

St. Tammany started the ED navigation program on a trial basis in March 2019. Since then, it has produced a significant return on investment with financial savings, along with ED avoidance, decreases in acute admissions, and referrals out of the community. The program has saved the hospital about $850,000 over a year, Nevers says.

The hospital hired social workers to cover the ED 16 hours a day, seven days a week. It also is planning to add an ED navigator seven days a week for 12-hour shifts. “The return on investment has been astronomical,” Nevers says.

Overall satisfaction also has improved. “Patient, staff, and family satisfaction has increased dramatically,” says Bradley Leonhard, BSN, RN, department head, emergency services at St. Tammany Health System. “Placing a team in the emergency room allows patients to get in and out quicker, and gets patients to the right setting. Having our navigator on hand to handle those [social determinants of health] problems allows us to care for patients, and not have to deal with the social aspect.”

The ED had assessed patients for psychosocial issues prior to the implementation of the ED navigation team, but most of those patients were placed in observation, says Michael Hill, MD, vice president of quality and utilization management at St. Tammany Health System. “We’ve cut out that piece completely,” Hill says.

Instead, the team works to find primary care providers (PCPs), specialists, and other services for patients. The team also addresses the social determinants of health that drive so many repeated visits to the ED, Hill explains.

“Over half of the emergency department visits are driven by social determinants of health, lack of medication, lack of linkage to medical resources, living in food deserts, and lack of social support at home,” Hill says. “We help with these things, in addition to getting patients to the right care provider and getting them support.”

For example, some patients use the ED because they do not have access to a PCP. This is due to lack of insurance, lack of transportation, or because they do not know how to find a doctor under Medicaid, says Angela Gottschalk, BSN, RN, CCM, department head of care coordination at St. Tammany Health System.

The ED transition team can help patients find a PCP and obtain transportation through Medicaid services or local service organizations. “The RN care coordinator plays a huge role in working with the social worker for these services,” Gottschalk says.

Educating patients is a major role for the ED team, Hill notes. “Many of these patients are not literate in medications, or the medical disease process,” he says. “We’re simplifying it for the patient, and linking patients to appointments for the next day.” This is an important part of closing the loop, Hill adds.

The ED navigation team is expanding its follow-up to a texting service, Nevers says. “An artificial intelligence program that we’re using in the emergency room with patients will send them an email or use a text messaging service with questions they can answer to help alert the team of the need to step in, from a navigation perspective,” she explains. “We learn whether they are able to fill their medication or make a follow-up appointment — any issues that would prevent them from coming back to the emergency room.”

Patients receive a message, inviting them to join the platform and activate an account. Then, the team sends canned questions, such as:

• Did you fill your medication after discharge?

• Did you make your follow-up doctor’s appointment?

• Is your condition worsening or getting better?

• Do you need any help?

Depending the patient’s answers, the program might send another question. For example, if a patient has not filled prescriptions four days after discharge because the cost was too high, he or she may receive a message, asking “What could we do to make your medication more affordable?” Nevers says.

The hospital is piloting the texting program, which began in January, to see how involved it is and if it will close the loop of care after patients are discharged, Nevers says.

“We’ve been working on this program for a while, and have done testing on it,” Hill says. “We’ve realized that healthcare is about people, and we have to reach beyond the four walls of the hospital, working with people once they leave the hospital, making sure they have follow-up and get all the right medications and appointments.”

Using the texting program, the team can stay in touch with patients about various clinical conditions. The data it collects can be used in a dashboard and screening tool that helps the team focus on the most vulnerable patients, Hill adds.


  1. Kanzaria HK, Niedzwiecki M, Cawley CL, et al. Frequent emergency department users: Focusing solely on medical utilization misses the whole person. Health Aff 2019;38:1866-1875.