For success with frequent ED utilizers, take steps to understand patient needs, connect them with appropriate resources

Robust effort requires time, effort, and a willingness to reach out to patients, providers

No one wants to see the ED used inappropriately, but it can be particularly frustrating when patients keep coming back with problems that never seem to get resolved. The reasons for such utilization patterns can vary, but what most repeat ED utilizers lack is any kind of consistency in their care, explains Sandi McIntosh, RN, the director of Emergency Services at St. Luke’s Hospital in Cedar Rapids, IA. The hospital is a level 3 trauma facility that sees about 156 patients per day in the ED.

“If a patient comes into the ED five times, the likelihood that he or she will see the same provider each time is pretty slim,” she explains. And the situation can become particularly complicated when the primary care provider (PCP) and any specialists the patient may be seeing are not in the loop when the patient presents to the ED.

Recognizing a clear opportunity to improve care for these patients while also reducing repetitive trips to the ED, in 2011 St. Luke’s took advantage of a $50,000 grant that it received from Transamerica to develop its Consistent Care Program, an approach that routinely identifies frequent ED utilizers and attempts to connect them with the kind of care and resources they really need.

In just one year of operation, the program has reduced the number of ED visits among frequent utilizers by one-third and generated close to $1 million in savings for the hospital. As a result, the Consistent Care Program has now been made permanent at St. Luke’s, and the Iowa Health System is thinking about expanding the approach to its other hospital facilities.

Establish care plans for frequent utilizers

Patients aged 18 and older are flagged for the program when they have visited the ED 12 times in 12 months. The names will come to light automatically through a computer-generated report that is created once a month, explains Sallie Selfridge, LBSW, the case manager for the Consistent Care Program. A committee, which includes Selfridge, as well as ED physicians and nurses, will then contact the identified patients and begin to develop care plans that take into consideration the reasons for previous ED visits, treatment received during these visits, and any information the committee is able to gather from other providers who have been involved with their care.

From this point forward, whenever one of these patients presents to the ED for care, the hospital’s electronic medical record (EMR) system will immediately indicate that the patient is a participant in the Consistent Care Program, and there will be a link to the care plan that has been created for the individual. “On the tracking board in the ED, we have built a column that is just for this program, so when a patient comes in, there is a little suitcase [icon] that identifies him or her as being a participant in the program,” says Selfridge.

If Selfridge is in the hospital when a program participant presents to the ED, she will go down to the department and meet with the patient. “This always involves interaction with the ED staff about what the visit is for, and then too, I will inform them about what I have learned from working with the patient,” explains Selfridge. “If it is someone I have been working with for a while, chances are that I have had contact with their primary care physician, and if they have been working with any supporting community agencies, then I have had contact with them as well.”

Interact with patients, providers

Many of the patients who participate in the program have complicated needs, and it can take considerable time and effort to get them stabilized. For example, Selfridge recalls the case of one woman who had uncontrolled migraine headache pain. “When I first started working with her, she had had about 14 ED visits in one month,” she explains.

Selfridge first contacted the patient’s PCP, who indicated that the woman should not receive narcotics for her migraine pain when she presents to the ED because they cause more severe rebound headaches. Selfridge then arranged for the woman to see a pain specialist.

“Once she got established with that physician, we worked with the pain specialist and her PCP to develop a care plan for when she comes into the ED during off hours,” says Selfridge, noting that the patient was able to go to the hospital’s outpatient infusion center for treatment during the day, but if she needed to be seen in the late evening or during the weekends, the ED needed a consistent plan for how to treat her.

“The patient was aware of the care plan, and it worked out great because everyone was on the same page,” says Selfridge. The patient’s ED visits gradually decreased throughout this process as the severity of her migraines lessened. And when the pain specialist she was seeing retired, Selfridge was able to transition the woman into a university-based program for migraine sufferers. “For the past three months, she has only had to visit the ED one time,” adds Selfridge.

Another case involved a man who kept coming to the ED for care because he couldn’t get in to see his PCP. “He had an outstanding bill at his PCP’s office from a period during which he didn’t have insurance,” explains Selfridge. “The office wouldn’t let him come back in to be seen until he paid that bill, so he was using the ED as an alternative.”

Selfridge first tried to work with the PCP’s office to come up with some sort of payment plan, but when that proved unsuccessful, she set the patient up with a new PCP. “He has called me a few times since then to tell me how great he feels and how well is doing,” says Selfridge. “He really likes the new PCP, and she is the one who is coordinating his care and getting him in for the tests he needs.”

Consider data, logistics

In most of the cases Selfridge has intervened with thus far, she has been able to reduce patient reliance on the ED. Out of the original 103 patients who were first identified for participation in the Consistent Care Program on January 1, 2012, she notes that only 10 patients still meet the criteria of having 12 visits in 12 months. For the time being, however, she is reluctant to remove any of the apparently stable patients from the program, even though about 10 new patients are added to the program each month.

“If we removed them from the program, or they graduated from the program, then they wouldn’t be on my radar,” explains Selfridge. “The concern is if their visits started to spike again, then we wouldn’t know about it until they hit that 12-visits-in-12-months threshold again.”

At this point, Selfridge says she would rather keep all the identified patients in the program, even if their medical and social needs have been stabilized. She also emphasizes that the intent of the program isn’t to keep patients from utilizing the ED. “The intent is to have them come in if they have an emergency. Then let’s look at their other medical needs and get them met in the most appropriate setting,” she says.

McIntosh’s advice to colleagues interested in developing a similar program is to take a good hard look at your data and analyze what your criteria for participation in the program should be. “Pulling data can sometimes be very difficult,” she says. “Is it accurate? Also, what are the logistics of how you know that a patient should be in the program?”

Having a mechanism embedded in the EMR that automatically identifies patients who meet program criteria is important as well, explains McIntosh. And she emphasizes that you have to have your physicians, nurses, and social workers on board. “Ours were very engaged,” she says. “If we didn’t have that, I don’t think the program would be successful.”

Sources

• Sandi McIntosh, RN, Director of Emergency Services, St. Luke’s Hospital, Cedar Rapids, IA. E-mail: mcintosh@crstlukes.com.

• Sallie Selfridge, LBSW, Case Manager, Consistent Care Program, St. Luke’s Hospital, Cedar Rapids, IA. E-mail: selfridge@crstlukes.com.