By Melinda Young


A case management program that focuses on social determinants of health helped a hospital system reduce revisit rates in its ED.

  • The ED’s re-visit rate dropped from 6% to 3%.
  • The hospital placed a care coordinator in the ED to focus on frequent visitors and help patients with medicine and chronic care barriers.
  • Focusing on transportation and access to care issues, the care coordinator helps patients schedule appointments with community providers.

A health system’s ED reduced revisits through a focused program to help patients with their social determinants of health.

“Our emergency room [serves] a huge refugee population,” says Lené Hudson, MSN, RN, CCM, director of care management at Valleywise Health in Phoenix.

Patients often present with chronic medical and behavioral health needs, along with two or more social determinants of health issues. These put patients at risk for returning to the ED.

At the health system’s level 1 trauma care campus, more than 60% of patients have significant behavioral health problems, Hudson says.

The ED’s revisit rate is 6%, which the health system decided to improve through case management-type services. The revisit rate was cut in half, Hudson says.

“We looked at throughput, observational data, and avoidable admits,” Hudson explains. “We focused on avoidable observations, rather than inpatient admissions.”

For instance, patients were placed in observation care when they did not meet the criteria. When this occurs, the real issue might be social determinants of health, she says. “We didn’t have good mechanisms for tracking social determinants of health, and we wanted to know how to look at that,” she adds.

Also, they reviewed ED visit volume and found it would be beneficial to place a care coordinator in the ED. There already was a social worker, who was available to handle inner-city trauma cases, including burns, stabbings, and gun violence.

As part of the research, Hudson and a nurse reviewed data on frequent ED visitors and found a way to see what was happening in real time.

“We created a little system where every time a person came back to the ED, a little boomerang appeared,” Hudson says. “That would be a target for a staff person to say, ‘This person came in more often.’”

Then, someone would talk with the patient and perform a high-level screening. “We asked the basic elements about transportation, money, access to care, and other basic screening questions,” Hudson explains.

“We have a large population that will use our ED for primary care,” she adds. “But there are other patients that we can help access care and connect them to our clinic. We can do specialty referrals and work with them to get those visits scheduled.”

The care coordinator can follow up with those patients to ensure they visited the clinic. “They can break down barriers of why they couldn’t get there, or why they’re coming back to the ED,” Hudson says.

After a pilot period, they found that two major barriers were care access and a cultural component. “We had patients who were refugees, a Hispanic population, and a lot of people who just didn’t know how to connect to care,” Hudson explains. “We had a transitional care coordinator who would make this follow-up call within the time frame to make sure they got care.”

Once patients from the ED were connected with a clinic, they could be helped by ambulatory care coordinators.

This is how the ED care management program works:

• Obtain stakeholder buy-in. “You need the right stakeholders to buy in,” Hudson says. “You want to build a trusting relationship.”

Case managers can do this by following their words with actions. “We worked closely with the medical director in the ED as a physician champion and talked about the benefits of connecting patients to care,” she explains. “One physician championed this to all providers, helping us.”

When providers asked for something, such as obtaining a specialty referral for a particular patient, the care coordinator helped build a referral process for them.

“We had the physician champion be part of those discussions, asking, ‘What do you want to see, and how do you want to see it?’” Hudson says.

• Know the population. “Know your population that is vulnerable and comes into the emergency department,” she says. “We look for those frequent flyers — anyone with two or more visits into our system and at least one inpatient readmission within 30 days.”

The program does not focus on medical diagnoses, but does look at barriers and social determinants of health.

“What we found is if we break down the barriers, the diagnosis is not the problem. The problem is access to care,” Hudson explains. “The issues are medication, transportation, access to care, and cultural problems.”

• Create the intervention. Creating a care plan is the easy part. Obtaining the patient’s buy-in is the biggest challenge, Hudson says.

For example, Hudson saw a patient who returned often to the ED because of fatigue, nausea, and vomiting. The person had visited the ED four times, resulting in a boomerang alert.

“I went to interview the patient, introduce myself, and explain my role,” Hudson says. “I asked about the person coming into the ER to see what we needed to do to connect them to care and get a medical history.”

Using active listening skills, Hudson learned that the patient was diabetic and had no money to pay for insulin. Plus, the patient lost the glucometer and could not refill medications. Transportation to a primary care clinic also was an issue.

“Right there, I have four potential interventions,” Hudson says. “I asked about the living situation to see what’s been done and what needs to be done.”

Sometimes, a patient needs to be connected with behavioral health partners in the community, she adds. “We can get all the interventions completed during the ED visit,” Hudson says. “We can get providers to help get that patient’s medications filled.”

Some health plans provide transportation assistance. For patients without insurance, the case manager could help them find transportation assistance or develop a transportation plan that could include bus passes or taxi rides.

• Determine criteria. The main social determinants of health are problems with transportation, food, and poverty, Hudson says.

Other criteria for ED case management assistance include patients who have visited the ED three or four times within the previous six months, and any patient with an unscheduled, 30-day readmission to the hospital within the past six months, she says.

Patients who take five or more medications, or record an admission risk score of five or greater, meet case management criteria.

• Form partnerships. “One key nugget is your community partnerships,” Hudson says. “You have to know who to call to say, ‘I have this patient. Can you take him?’”

It is important the person in this role has a good sense of clinical decision-making, and a good network relationship with community partners and their care coordinators, she says.

“If I am trying to schedule a patient in the primary care provider clinic, and it’s totally full for tomorrow, how do I get that patient in?” she says. “You need to know those escalation processes of how to get that patient in.”

• Provide weekend help. Social workers are in the ED continuously, but the care coordinator role is limited to Monday through Friday, working hours.

“When we’re here, we meet with patients,” Hudson says. “Say a provider at 8 p.m. wants someone to follow up with a patient. It goes to our work queue.”

When Hudson arrives in the morning, she sees referrals from the previous night and can handle them that day.

“They can do telephonic help at night and on weekends,” Hudson says.