Patients who use the healthcare system excessively, and often for avoidable issues, create a burden for hospitals and consume a significant portion of healthcare expenditures.
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Many frequent users have complex medical and psychosocial needs, are uninsured, or have behavioral health issues.
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Case managers should identify patients who are potential frequent utilizers and make sure they are connected with a primary care provider.
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Take the time to find out barriers to care and call in a social worker to help line up community resources.
You may refer to them as "frequent flyers," "familiar faces," or "super utilizers," but whatever term you use, when members of this group of patients show up in the emergency department, you may think,"Oh, no. Here we go again."
Every hospital has patients it sees over and over, often for preventable conditions or problems that could be treated in a lower level of care. According to the Agency for Healthcare Research and Quality, the top 1% of healthcare users account for 21.4% of healthcare expenditures. In this issue of Hospital Case Management, we'll show you what case managers are doing to help patients avoid unnecessary hospital visits and to seek treatment in an appropriate level of care. You'll learn how one hospital's "red carpet treatment" has cut hospital visits among super utilizers, how embedded case managers target high utilizers, and how dealing with social issues helps keep patients out of the hospital. We'll describe a communitywide approach to mental health transitions and a program to help emergency department patients navigate the health system. It's all in this issue of Hospital Case Management.
Hospitals are inundated by patients who frequent the emergency department when they have a sore throat, a fever, or another minor complaint; those who come to the emergency department looking for a prescription for narcotics; and those who have complex or chronic conditions, don’t follow their treatment plan, and end up back in the hospital.
A report by the Agency for Healthcare Research and Quality concluded that the cost of care for the top 1% of healthcare users accounted for 21.4% of the total spent on healthcare in the U.S. in 2010. The tab for these super utilizers, on average, was $87,570, according to the report. (The report is online at http://meps.ahrq.gov/mepsweb/data_files/publications/st421/stat421.shtml.)
"As we experience changes in the payment structure, all health systems are looking at who their frequent utilizers are, why they are coming to the hospital, and what we can do to get these patients connected to routine medical care so they will stay out of the emergency department and avoid readmissions," says Jason Hyde, LMSW, M.Ed, assistant vice president for community case management at Lutheran HealthCare in Brooklyn, NY.
Much of the care that frequent utilizers receive appears to be avoidable, says Brent Williams, MD, MPH, associate professor of internal medicine and medical director for the University of Michigan Complex Care Management program.
"These patients are in the emergency department and hospital because of a complex set of social, medical, and sometimes psychiatric needs, as well as lack of insurance. These patients are using a lot of resources, but with the right support and care coordination, they could use less," he says.
Not all patients who consume a lot of resources fall into the super-utilizer category, Williams points out.
"When we looked at our own high utilizers and the reasons they were readmitted, we found that about a third were readmitted for unavoidable medical issues, such as catastrophic illnesses, organ transplants, or chemotherapy," Williams says.
Many super utilizers don’t have their own physician or don’t have the resources to pay for a primary care provider or their medication, so they end up going to the emergency department and often being readmitted, says Linda Sallee, MS, RN, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.
Other frequent users are non-adherent because they don’t understand their treatment plan or don’t want to follow it and end up in the emergency department again and again when their chronic conditions get out of control, she says. Some frequent utilizers have psychiatric issues that make them difficult to deal with, or they come to the emergency department over and over seeking pain medication, Sallee says.
"Whatever the reason, when patients frequently visit the emergency department and/or are hospitalized when another setting would meet their needs, it creates a burden for hospitals, especially since insurers began penalizing hospitals financially for readmission. But we also know that receiving primary care in the emergency department and being readmitted to the hospital is not the right thing for patients," she says.
Often, overuse of the emergency department is a system problem as well as a patient issue, says Donna Zazworsky, RN, MS, CCM, FAAN, vice president, Community Health and Continuum Care for Carondelet Health Network in Tucson, AZ.
"If a patient lives on one side of town and the only place he can get care is across town, it’s unlikely that the patient will see a primary care provider even if someone coordinates transportation. If there’s not a primary care provider in a convenient location, patients are going to use the emergency department," she says.
A significant portion of super utilizers have mental health issues as well as medical problems, Hyde points out. "There is a huge need to coordinate physical health and mental health services for all patients, but particularly among high utilizers," he says.
If they are depressed or psychotic, they may not get their prescriptions filled or take their medication regularly, Hyde says. "Mental health issues have a huge impact on a patient’s ability to access physical health services and to adhere to their treatment plan," he says.
Traditionally, mental health providers and physical health providers have operated in silos because of privacy issues, Williams says. "But we are recognizing that chronic medical conditions affect many people treated by mental health providers. The average person with severe mental illness has a life expectancy 20 years shorter than their counterparts without mental health issues. They are dying from complications of diabetes and coronary artery disease, not mental health conditions," he says.
Helping patients connect with a primary care provider should be a priority for hospital-based case managers whether they are in the emergency department or the acute care unit, Zazworsky says.
Case managers should identify patients who have the potential to be readmitted or return to the emergency department before they become a frequent utilizer and develop a discharge plan that helps them stay out of the hospital, Sallee says.
Hospitals need to have case managers in the emergency department to develop a care plan that may help frequent utilizers seek care in a more appropriate venue, Sallee says. "We don’t give people an alternative to thinking of the hospital when it comes to seeking healthcare. For some people, it is simply easier to go to the emergency department. Patients who do not have a payer source may wait to see a provider until their condition is so serious they need to be admitted," Sallee says.
Few hospitals have case managers on duty 24-7, and even if they do, case managers are so busy that they don’t take the time to sit down and talk to patients to find out what really is going on with them, says Peggy Rossi, BSN, MPA, CCM, a retired hospital case management director who now is a consultant for the Center for Case Management.
When patients are hospitalized or visit the emergency department, case managers should spend time with them and drill down to find out the reasons they are in the hospital. In addition to looking at their healthcare problems, it is important to find out their financial status, support system, and psychosocial needs, Rossi says.
"Case managers usually don’t talk to patients about whether they can afford their medication or the cost of a primary care visit. Case managers should determine if patients need to be referred to assistance programs and explore other options to avoid another emergency department visit or hospitalization," she says.
If patients are insured or receiving Medicare or Medicaid benefits, talk to the case managers at their plan to find out what medications they are taking, whether they are seeking care or drugs in other facilities, and collaborate with them on a plan of care, Rossi suggests.
"We’ve got to communicate across the continuum to ensure that patients get the best possible care at the right time and in the right setting," she says.
Sallee suggests a social work consultation for patients who are frequently readmitted or visit the emergency department with regularity. "There may be a lot of underlying issues, like problems getting medication or behavioral health problems that cause them to come back over and over. It’s better to identify their issues and try to fix them rather than treating them every time they come in and sending them back to the same situation that brought them to the hospital," she says.
Social workers can help patients access community resources and transition patients with behavioral health issues to a provider, she says.
Hospitals have to do whatever it takes to break the cycle of frequent utilizers, Sallee says.
"When people get better healthcare in an appropriate setting, they have a better experience and achieve better outcomes, which in turn reduces unnecessary expenditures," Hyde adds.
