Case managers are at an advantage when they can make informed decisions from electronic medical record (EMR) data and other sources. One way they can use the data is by identifying patients who might be at risk of frequent emergency department (ED) visits.

These repeated visits certainly affect the patient’s quality of life, but also affect health system costs, availability of beds, and overwork for the ED staff.

“There are several data elements that can be leveraged, and medical records today are coming out with new, compelling technologies in machine learning to break the cycle of emergency room overutilization as well as socially motivated visits,” notes Jeff Echternach, MBA, AAS, NRP, technology officer for The Center for Case Management.

According to Echternach, some key data factors can help identify patients in this situation. Case managers should consider:

  • history of frequent visits and/or patterns;
  • recent no-show visits from the primary care provider (PCP) or specialist;
  • inability to schedule an appointment with PCP or specialist within 45 days of request;
  • inability to afford medication;
  • access to transportation;
  • no PCP and has one or more chronic condition;
  • visit history reports and utilization pattern reports;
  • ED visit reports;
  • no-show reports.

Taking Notice

Quickly identifying high ED utilization early is key to finding a way to end the cycle. There are several ways case managers can look for this activity.

First, Echternach says, “risk factors for high utilization can be recognized in the ambulatory setting or through pre-screening programs conducted by ambulatory or outpatient case managers. These might include social determinants of health, whether the patient can afford their medication, and whether they have access to a PCP.”

Second, risk factors like unaddressed chronic conditions can be recognized via payor case management programs and risk surveillance.

“When a patient has a chronic diagnosis without a PCP, or the lack of a timely PCP visit, it can lead to increasing utilization,” Echternach notes.

Working to see the patient as a whole person, considering his or her past and current circumstances, is necessary to gain insight on their needs and habits.

“When patients are missed by these first two programs, they often land in the emergency room. An assessment that includes components of chart review and external record review, such as prior questions from ambulatory encounters, is the best tactic to leverage all data available to form a complete picture,” Echternach explains. “A social determinants of health assessment is equally beneficial for a low-risk case.”

“Oftentimes, reporting and trends are the first catch for these patients,” he adds. “This can include information-sharing from ambulatory environments as well as payors. High utilization and rising risk utilization reports are sometimes a case manager’s best friend when creating a flag for patients who need follow-up.”

Preventing High Costs

Of course, identifying the patient is only half the battle. The real objective is to help create a plan to break the cycle of overutilization, which is a positive change for the patient, but also can prevent high system costs.

“Transitioning a patient from using the emergency room to a more appropriate care setting is not only beneficial to the patient, but is helpful to the hospital because the emergency room is the single-most expensive care setting secondary to the operating room,” Echternach shares. “In some cases, a frequent utilizer of emergency room care is taking up space for a patient who is experiencing a critical life threat. At times, these visits may not even be reimbursed, depending on the situation. There are numerous advantages to connecting the patient with the right location for their care.”

Once a patient in this situation is discovered, the case manager can learn more about the root causes of ED utilization and create an action plan among the patient, PCP, and case manager.

“Ambulatory case managers have the ability to triage overall risk and, when necessary, escalate a patient’s case for timely outpatient follow-up to mitigate future emergency room use and activate a sustainable plan,” Echternach says. “Ambulatory case managers often work together with payor case managers and emergency room case managers to support the needs of patients with increasing emergency room utilization.”

Tips for Interpretation

How can a busy case manager take the time to accurately identify these patients and create an action plan? They should not handle this task alone.

According to Echternach, help from the hospital is key to setting the stage for accessing and interpreting the data.

“Hospitals should establish guidelines that help case managers objectively identify high-risk and rising risk cases for high emergency room utilization. [They] should also consider building indicators into the electronic record whenever possible. Many of these indicators are covered in question one.”

Data analysts are another resource. “Case managers should work with data analysts to prepare reports on emergency room visit utilization by patient and visit disposition with consideration given for the initial visit acuity and other key factors,” Echternach says. “These reports should be detailed, and teams within case management should consider how they can review these reports for high utilization.”

Ambulatory case management programs also can establish similar reporting mechanisms for missed appointments and coverage of formulary changes whenever known.

“Patients with newly identified chronic conditions that are on a phone call or screening list should be asked key questions about access to transportation and affordability of medications,” Echternach notes. “A review of recent utilization should be performed. These data elements can be pulled together in a report to identify when a patient is increasing in utilization frequency, or when the patient appears to have difficulties getting access to primary care, which are warning signs for high utilization.”

Worth the Time

Echternach admits “the data analysis and maintenance of algorithms can be somewhat challenging” for case managers who already have full plates and might not have the technical expertise to carry out the work in a timely manner.

“However, this burden can be maintained by technical staff with more time returned to case management professionals to interpret the information and act upon the data,” he says. “Taking action on reports can take some time, depending on the accuracy of the tools that have been developed, and there can be even more potential risk identified in the ambulatory setting than in an ED report. In situations like these, case managers and their leaders should set a cutoff point at the utilization level or risk level they desire to intervene on.”

Overall, it seems to be worth the investment of time for the case manager to act on the data at their fingertips and make a plan for patients that will benefit them — and the hospital staff — now and in the future.

“One of the major opportunities that is lost when high utilization risk and rising risk data are not acted upon is the ability to influence health outcomes of the patients in your population,” Echternach says.