By Melinda Young


Using a navigation team with access to integrated data, an ED can connect patients to primary care providers, local organizations, and psychosocial programs.

The ED care management team can build bridges with local housing authorities and collect data on patients’ housing vulnerability.

The ED team can use a dashboard to collect information about patients’ home situations, their sociobehavioral health issues, substance use issues, and medical conditions.

The team can help patients set up appointments with community providers.

ED navigation teams can connect patients to primary care providers, psychosocial programs, and community-based organizations to help keep people out of hospital beds and the ED.

“There is value in integrated data,” 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.

Health systems can pull data from community providers whenever this information is accessible. “As an emergency department doctor, I work in a very busy system, and I don’t want to duplicate efforts,” Kanzaria says. “If I want to link a patient to social services, but the patient might already be linked, I don’t want to duplicate.”

Clinicians need to communicate and coordinate care between healthcare settings to reduce interruptions of care, as well as duplication of care. “These types of data could be used to advocate for services in the ambulatory care setting, and for outpatient care management,” Kanzaria explains. “It speaks to the high social needs of these clients.”

Homelessness is one of the chief social needs among frequent ED users, Kanzaria says. ED case management can be an opportunity for the health system to engage with patients in need of housing. For example, if a homeless patient seen in the ED has a skin infection on the leg, the treatment might be to elevate the leg and prescribe antibiotics, he says.

“We look for a service in the community where they can do that,” he says. “We offer to help patients get into transitional housing.”

The key is for the ED care management team to build bridges with local housing authorities, and to collect data on patients’ housing vulnerability, including their length of time homeless, mental health status, and other vulnerabilities. This information helps housing departments assess and rank them according to a housing prioritization list, Kanzaria adds.

One of the keys to the team’s success involves data-driven screening and decision-making. “We have different analytic platforms that we look at every day,” says Julie Nevers, MN, BSN, CCM, director of care coordination at St. Tammany Health System in Covington, LA. The dashboard provides information about patients who frequently return to the ED. It includes information about patients’ home situations, their sociobehavioral health issues, substance use issues, and chronic diseases and medical conditions.

With dashboard data on patients, an ED navigation team communicates with ED staff and others about the patients. ED staff might make a referral based more on their observation and experience than what is in the medical chart, Nevers notes.

“The ED staff will say, ‘I have a feeling something is not right with this patient. Do you mind looking into it?’” she says. “A lot of it is open communication and everyone believing in everyone’s discipline and believing in what value they bring to the team.”

St. Tammany Health System started its ED navigation team as a pilot project a year ago. The team includes an ED navigator, RN case manager, social worker, and utilization review professional.

“When we put our ED navigator in this role, she was actively having to seek out consults and things to do. Physicians weren’t quite sure of what her role was, and how they could utilize her,” says Angela Gottschalk, BSN, RN, CCM, department head of care coordination at St. Tammany Health System. “Today, they are actively seeking her out. The staff has come to realize how valuable she is in the emergency department, and how she could help them move their patients along the continuum.” The ED is proactive in seeking out the navigator, asking for help in moving patients along the care continuum, she adds.

It also is important that ED navigation teams know about community resources that can help patients with their social determinants of health and other problems. “It’s important that those who start the navigation program are aware of what resources are available in their market,” Nevers says. “They should have relationships with community providers.”

For instance, if an ED patient needs an immediate appointment with a primary care provider, the ED navigation team should be able to call a particular provider and ask for a next-day appointment. The provider, who has a relationship with the ED navigator, would know that this is an important case, and that the navigator would not ask for this favor lightly, she explains.

“You have to go out and meet community providers, and work together with them on projects,” Nevers says. “We’re fortunate here to have a robust community network that works well. Although there always is room to grow, we’re fortunate to have that teamwork approach that extends outside the hospital.”

St. Tammany’s ED navigation team has access to patients’ schedules in some physician offices. Sometimes, the team can schedule an appointment for a patient without having to speak with anyone in the office, Gottschalk says.

“Sometimes, we don’t have to call anyone, and we can schedule it right from the computer. That’s where building relationships and having trust helps,” she adds.