Tailor ED discharge plan to the individual

One size just won’t fit all

As case managers work with patients in the emergency department, they need to let each patient be the guide in creating a plan that will work, particularly when they coordinate care for patients with low socioeconomic status, says Shreya Kangovi, MD, director of the Penn Center for Community Health Workers and a Robert Wood Johnson Foundation Clinical Scholar in the Department of Medicine at the Philadelphia Veterans Affairs Medical Center.

"Case managers need to think outside the box and take a more patient-centered approach instead of a one-size-fits-all plan and develop strategies that meet each patient’s individual needs," she says.

Kangovi was lead author in a study at Penn Medicine that examined the reasons low-income people use the emergency department rather than seeking care in a physician’s office. Researchers worked with trained community health workers to conduct detailed interviews with 40 Philadelphia patients who were low income and uninsured or Medicaid recipients to find out why they choose to visit the hospital emergency department instead of seeing a primary care physician.

Primary care and preventive care are riddled with barriers that drive patients away and into the emergency department, Kangovi says. Patients told researchers that when they call their primary care providers, the phone is rarely answered by a real person, they often have to wait weeks to see the doctor, and they have to take time off work and line up transportation. Then the primary care provider may send them to one or more specialists and they miss work again, have another co-pay and more transportation issues.

"All of us can relate to the problems with the healthcare system that these people face. The difference is that low-income people don’t have the resources to work around the dysfunctional healthcare system. They can’t just take a cab or take a day off work with pay or afford the co-pays. They have to wait and use the hospital and receive care that is costly," she says.

Low-income people are not coming in to the emergency department with non-emergent conditions, prior research shows. They tend to come in much sicker than higher-income people, with conditions that could be prevented. For instance, they may come in with an asthma attack that may be life-threatening but could have been be prevented.

"When we talked to the patients themselves, it became very clear that we have to debunk this perception that all we have to do is educate patients on the proper use of the healthcare system. Instead, the patients educated us on how the pitfalls to receiving care are caused by the way we have structured the healthcare system," she says.

As healthcare professionals redesign the healthcare system, they should let patients be their guide or the new system also will be broken, Kangovi says.

"Patients are the experts and can tell us how an idea that sounds good in a conference room will play out in real life," she says.

For instance, one of the strategies for patient-centered medical homes is open-access scheduling that allows patients to schedule same-day appointments with primary care providers.

However, low-income patients told the researchers that the idea often won’t work for them. They don’t have flexible jobs and to take a day off work, they have to schedule an appointment ahead of time. Many receive their care in clinics with few telephone lines and by the time they get through, all the slots are booked. They have to rely on subsidized transportation, and that has to be arranged 72 hours in advance.

"The devil is in the details and the patients should be our guide," she says.

The researchers looked at patterns among low-income patients who use the emergency department for primary care and found two distinct groups, each with a different set of issues. One group has experienced extraordinary trauma in their lives that resulted in social dysfunction and mental illness. For instance, one patient was a child when he came home from school, saw his father being arrested and never saw him again. Another witnessed the murder of a loved one.

Members of the other group report social stability and live in tight-knit communities. However, many of the people they are close to are ill and very poor. "These patients are too busy taking care of others to take care of themselves. They can’t take time off work to see a doctor when they get sick because the family relies on their paycheck," she says.

One strategy is to use community health workers, trained lay people who share life experiences with the patients, which makes them natural helpers within the community, she says. "There’s a lot of potential for this type of workforce. They have had similar experiences to those the patients face and can develop the rapport needed to figure out patients’ needs and the underlying problems," she says.