Study: ED-based care coordination interventions need to fit unique needs of ED settings, providers
Tackling the issue: Embed community health workers in the ED
To keep a lid on costs, health care policy experts recognize that hospitals need to find more effective ways to manage transitions. The care coordination piece can be particularly problematic in the fast-paced ED setting, and yet it can make a big difference in determining whether a patient receives appropriate follow-up after an acute event and whether he or she is back in the ED within days or weeks with another acute exacerbation of the same issue.
While the rationale for effective care coordination is clear, it turns out that identifying effective inventions for the ED setting is problematic, according to researchers who attempted to compare the effectiveness of ED-based care coordination interventions in a systematic review.1 "We know that certain interventions are more effective than others, but really the question for an ED manager is what is going to be the effectiveness of this particular intervention in my setting," explains Jesse Pines, MD, MBA, a co-author of the study and director of the Center for Health Care Quality and associate professor of Emergency Medicine Health Policy at George Washington University in Washington, DC. "I think different interventions are going to behave differently in different settings."
Pines adds that whether or not an intervention is effective depends not just on the quality of the particular intervention, but also on whether the local people in the ED implement the intervention in an effective way and whether the providers outside the ED are receiving the information and really connecting with the ED. "One of the themes of care coordination is that you basically need individuals or entities working with each other," says Pines. "Organizations and providers outside the ED need to be interested in working with the ED to improve care for their patients." (Also see "With aligned incentives, effective care coordination across multiple settings is easier to achieve," below.)
With these caveats in mind, the researchers did find that certain ED-based interventions were more effective than others at increasing follow-up rates or reducing repeat ED utilization, says Pines. For example, automatically making follow-up clinic appointments for patients has had some success, although the progress is variably effective across different settings, says Pines. Also, providing care coordinators for older adults has been shown to be effective in some studies, but most studies do not tell the whole story, he stresses.
"Our goal is that by improving care coordination, health is going to be improved and patients are going to be better linked in with a primary care provider who can follow them longitudinally, but, ultimately, the downstream costs are going to be lower because people are going to be healthier and they are going to use fewer health care resources," says Pines. "And the missing link in [the literature on this area] is really demonstrating that care coordination interventions are associated with big differences in downstream costs."
Form links with providers, organizations
One persistent barrier to effective care coordination is the fact that ED physicians are generally not incentivized to make the extra effort required to connect with other providers. "In order to make emergency physicians want to do this, there are a couple of things that need to happen," says Pines. "First, there needs to be an explicit incentive to [provide care coordination], and two, there needs to be systems in place to coordinate with. And those systems need to be built outside of the ED."
Indeed, Pine points out that it is the payers who will benefit most financially from achieving better quality care at lower cost. "One of the ways to reduce costs is to reduce downstream utilization through better care coordination, but essentially if it is the hospital that invests in the effort and the payers who are reaping the benefit, that is a problem," says Pines. "Everyone has to benefit. It needs to be win/win."
The newer payment models, such as accountable care organizations and bundled payments, are attempting to better align incentives and benefits, but the role of the ED in these new systems has yet to be determined, says Pines. "My vision would be that the ED becomes a critical part of the medical home, and that there is a free flow of information between the ED and the medical home so that everyone is on the same page with regard to care plans and it is easy to get rapid follow-up for people," he explains. "But essentially what that will require is not only a care coordinator who is present in the ED, but also a care coordinator who is online and available for outpatient clinics."
Pines adds that this type of coverage needs to be available 24/7 because, while it is easy to call a clinic during business hours, the majority of ED patients don't present for care during business hours. "I think trying to coordinate care with people during non-business hours is going to be one of the most effective things that clinics can do to help promote care coordination for their patients," he says. (Also, see "Effective care coordination within the ED begins with systematized communications," below.)
While it will take time for newer payment models to positively impact care, Pines advises ED managers to begin reaching out to organizations and providers outside of the ED. "Care coordination is about a dyad between two providers or a provider and a patient working together to come up with the best care plan, and one of the major things that is lacking right now is those linkages," says Pines. "I think the first step is to start creating those linkages and to develop systems that can improve care coordination in the future because once these new payment incentives roll out, part of the responsibility is going to be on the ED to insure that patients get follow-up and that their care is coordinated, both on the front end and on the back end."
Get to the root of health problems
The US Department of Health and Human Services (HHS) certainly believes that better care coordination between the ED and other providers is one of the primary keys to controlling costs. Health care organizations with specific plans to address this area figured prominently in the first round of Health Care Innovation awards that were announced in early May 2012.
For example, University Emergency Medical Services (UEMS), a team of emergency physicians that is affiliated with the State University of New York (SUNY), Buffalo, is set to receive $2.57 million in federal grant dollars to launch a program that will deploy community health workers (CHW) to help certain high-need patients who present for care in the ED get established with a medical home for routine medical care, as well as link up with any social services that can help these patients get their health and their lives on a better track.
"The current state of affairs is that EDs are silos in the sense that people show up there and they receive some care, and then they are sent back into the world where they will hopefully find their way into the other parts of the health care system," explains Anthony Billittier IV, MD, FACEP, dean, School of Health Professions, D'Youville College, Buffalo, NY, an attending physician at Erie County Medical Center in Buffalo, NY, and an assistant professor of emergency medicine at SUNY Buffalo. However, navigating the health system is very difficult, adds Billittier, noting that he has even had trouble navigating the health system with his own family. "What the community health worker system will do is once we send patients on their way, we won't actually leave them, at least not immediately."
Instead, Billittier explains that the CHWs will follow these patients out into their communities where they live and work and help them with any follow-ups they need from a medical, social, or environmental standpoint. "The CHWs will do what they can to make the patients' lives better, so the end-game here is that they will have better health and they won't need to come back to the ED again, or at least not for things that are not true emergencies," he says.
Billittier adds that a key thrust of the CHW model is to address health in a more comprehensive way. "The [traditional] health system sort of ignores the social determinants of health," he says. "Very often we think that if we give people a pill or give them an operation or take some other medical intervention, we are fixing their health care problems, but the reality is that the root of their problems is really seated in their socioeconomic [circumstances] and their environment, so until we begin to deal with those issues, we are only going to continue to give them pills and operations and those sorts of things."
For example, to get at the root cause of their health problems, some patients may require life coaching, and they may need help in getting plugged into non-medical social services such as food stamps or workforce development programs, explains Billittier. "We think if we can help them with some of their non-health-related issues, their health problems will then be that much easier to solve, so that really is the foundation of the program," he says. "We have to get them into a medical home. That has to be part of this, but that is only half the battle."
Derail inappropriate ED utilization
The CHW model is not new, but it has gotten results in other health care settings, observes Billittier. "Community health workers have a track record of being effective at life coaching and helping their peers," he says. "That is the whole point of community health workers. They are really peers of people, and that is why they are effective."
The health system has contracted with D'Youville College in Buffalo, NY, to help recruit the 10 CHWs that will be deployed in the two EDs that are participating in the program, Erie County Medical Center and Buffalo General Medical Center. "The college is going to train our CHWs, using standardized models," explains Billittier. D'Youville will then work collaboratively with UEMS to provide ongoing education to the CHWs and to address any issues that come up that require added training.
"We don't know yet exactly how we will need to retool, but D'Youville will develop training programs on various issues that are needed, and they will also help us with some quality oversight," explains Billittier. "That goes hand-in-hand with the ongoing educational component."
Billittier emphasizes that for the UEMS model to work, the CHWs need to be embedded in the ED. "What is going to happen is a community health worker or a community health worker supervisor is going to need to spend time in the ED case finding," he explains. "However, the CHWs are going to spend most of their time out in the community because that is where their real work is going to be done. To be effective, they have to interface with people where they live, learn, work, and recreate every day, but the linkage has to be made right in the ED."
Billittier envisions that especially in the early stages of the model's implementation, the CHWs will be building their caseloads while working in the ED side-by-side with the emergency physicians to identify patients who have a high likelihood of coming back to the ED. "We have defined these patients as people who have already used the ED two or more times [in the previous 12 months]," explains Billittier. "These will be people who already have a history of using the ED, and I think there is pretty good [evidence to suggest] that they are going to continue to use it."
There will undoubtedly be times when the CHWs will be faced with medical issues that they are not trained or equipped to handle on their own. Consequently, another component of the model is that there will always be three emergency physicians on call to make medical judgments or to intervene, as needed, explains Billittier. For example, an emergency physician could determine whether a patient who was discharged from the ED with pneumonia on the previous day needs to come back to the ED for added treatment, or he might get on the phone with the patient's primary care provider (PCP) to explain the patient's clinical circumstances and to arrange a speedy follow-up appointment.
The basic idea is that through the work of the emergency physicians and the CHWs, the repetitive, inappropriate use of the ED will be derailed and the patients will be linked into a more appropriate care setting for their routine medical needs. Also, since the program is an initiative of the Centers for Medicare and Medicaid Services (CMS), the CHWs will focus their attention, at least initially, on Medicare and Medicaid patients.
"Our long-term target is [for CHWs to work with] anyone who needs the service, regardless of the payer, or lack thereof, because that is how we approach patients in the ED," says Billittier. "As clinicians, we don't even know what type of insurance patients have, and we don't care. We provide the same level of care, so, ultimately, that is the way the system needs to go forward."
Administration of the CHW program will require a director and two social workers to supervise the CHWs, but program developers are aiming to save more than $6 million over a period of three years.
- Katz E, Carrier E, Umscheid C, Pines J. Comparative effectiveness of care coordination interventions in the emergency department: A systematic review. Ann Emerg Med. 2012 Apr 26. [Epub ahead of print]
- Anthony Billittier IV, MD, FACEP, Dean, School of Health Professions, D'Youville College, Buffalo, NY, Attending Physician, Erie County Medical Center, Buffalo, NY, and Assistant Professor of Emergency Medicine, State University of New York, Buffalo, NY. E-mail: Billitti@dyc.edu.
- Justin Chang, MD, Chief of Hospital Operations, Kaiser Permanente, Denver, CO. Phone: 303-344-7518.
- Adam Hill, MD, Regional Department Chief, Department of Emergency Medicine, Permanente Medical Group, Denver, CO, and Medical Director, Emergency Department, Exempla St. Joseph Hospital, Denver, CO. Phone: 303-344-7518.
- David Kaleugher, MD, Assistant Regional Department Chair for Emergency Medicine, Kaiser Permanente, Denver, CO, and Senior ED Champion, Exempla St. Joseph Hospital, Denver, CO. Phone: 303-344-7518.
- Jesse Pines, MD, MBA, Director, Center for Health Care Quality, and Associate Professor, Emergency Medicine and Health Policy, George Washington University, Washington, DC. E-mail: Jesse.Pines@gwumc.edu.
- Shari Welch, MD, FACEP, FACHE, Fellow, Intermountain Institute for Health Care Delivery Research, Salt Lake City, UT, and President, Quality Matters. E-mail: Shari.Welch@thequalitymatters.com.
With aligned incentives, effective care coordination across multiple settings is easier to achieve
As a fully integrated health care system that uses a prepaid, capitated financial model, Kaiser Permanente (KP) has a number of advantages when it comes to care coordination, but the most significant advantage is that all the providers in the system are focused on the same quality metrics, according to Justin Chang, MD, the chief of hospital operations at Kaiser Permanente, Colorado. "It is a very difficult thing, but it inherently works within our system because the primary care physicians, the ED physicians, the hospital physicians, and the physicians who work in skilled nursing facilities (SNF) all completely have aligned incentives," he says.
This enables KP to operate like an accountable care organization (ACO) in which accountability for a patient's care is shared throughout the continuum, regardless of where the patient enters the system. Consequently, even though the ED is a very episodic venue, it is considered within the whole context of the patient's medical history, explains Chang. "There are no conflicting financial incentives about what is going on," he says.
While no system is perfect, the KP experience offers some interesting lessons to hospitals and health systems that are moving toward the ACO model. Not everything that KP does will translate to hospitals that still work in more of a fee-for-service environment, but some of the care coordination processes that KP has in place are worth considering. For example, at Exempla St. Joseph Hospital in Denver, CO, KP providers have standardized the way they handle patient transfers from the ED to an SNF.
"We essentially sat down with our SNF providers three or four years ago and asked them what were the things that they were not consistently receiving when the ED sends them a patient," explains Adam Hill, MD, the regional department chief, Department of Emergency Medicine, Colorado Permanente Medical Group, and medical director, Emergency Department, Exempla St. Joseph Hospital. "It is easy to drop the ball when passing on information, so we standardized a computer-based template based on the information that was given to us by the SNFs."
The template includes such information as:
While KP does not own or operate Exempla St. Joseph Hospital, it partners with the hospital so that the computer systems are linked and the ED providers can access patient medical records through the KP system. "As an ED provider, when someone is sent in from a KP clinic, I can see not only the records from that clinic visit that day, but I can also see historic information," explains Hill. "I can get an idea of the patient's trajectory of care and I can see the concerns that the clinic provider had."
Conversely, when the patient is discharged from the ED, the clinic provider will get an automatic summary of what happened during the ED visit, including what the test results were, what the provider's thoughts on the patient were, what therapies the patient received, and what the plan was upon discharge, adds Hill. "These are important ways that we close the loop for the Kaiser patients that we see in the ED," he says.
Hill explains that KP providers make an effort to forge similar linkages with the providers of non-KP patients who present to the ED for care. For example, a number of private practices in the area have activated what Hill describes as an "auto-fax" function that will kick in if one of their patients is treated in the ED. "If that patient is discharged back home after an ED evaluation, we will send a fax copy of the ED visit to the primary care provider's office," he explains. "It is far more reliable to have a systems solution for sharing that information back than it is to rely on the human brain to remember to call the primary care physician later."
Beef-up resources for older patients
Administrators at Exempla St. Joseph Hospital and KP believe they can make further improvements in care coordination through a new initiative that is focused on bringing more of a geriatric focus to the ED. Called EMBRACE (emergency medicine bridging acute care for the elderly), the initiative will make new resources available to the ED so that older patients who present with non-emergent needs will receive more comprehensive care.
"If you look at the patients aged 65 and older that we see in the ED now, the rate of return within 30 days ranges between 15% and 20%, so by integrating palliative care services and senior care coordinators and our hospital team, we hope to be able to impact that rate of return," explains David Kaleugher, MD, the assistant regional department chair for Emergency Medicine for KP in Colorado, and the senior ED champion at Exempla St. Joseph Hospital.
The model, set to debut early this fall, will include some environmental modifications and education for both the nursing staff and physicians. It will require ED staff to view the ED visit not as an "episodic blip in the patient's history," but more as an opportunity to make the necessary interventions that the patients would receive if they were making a clinic visit, explains Chang. For example, a senior patient visiting the ED for care might receive screens for nutrition, dementia, polypharmacy, and other care that is typically not completed in a traditional ED.
While the concept of a senior-focused ED is not new, it is perhaps easier to implement in a system where the financial incentives are fully aligned, observes Chang. "The strategy could be deployed in any ED as long as you actually re-think what you believe the mission of your ED is — not quick disposition, but actually the entire continuum of care," says Chang. "The reason we are doing it here is because we already have senior care coordinators and chronic care coordinators who deal with chronic conditions in the clinics already. They already know the patients, or will soon get to know them."
Effective care coordination within the ED begins with systematized communications
While effective transitions between health care settings is a vital component of accountable care, some EDs would be well-advised to begin their improvement efforts by shining a spotlight on their internal operations first.
Many breakdowns in care coordination occur because communication within the ED is not systematized, stresses Shari Welch, MD, FACEP, FACHE, a fellow at the Intermountain Institute for Health Care Delivery Research in Salt Lake City, UT, and president of Quality Matters, an emergency medicine consulting firm. "Caring for ED patients involves multiple queues and at least a half-dozen processes at a minimum. Communication is haphazard and, often, the clinicians are forced to chase clinical data," she explains.
For example, Welch says it is not uncommon to see clinical staff running around, asking each other whether particular care tasks, such as lab work, CT scans, or follow-up phone calls, have been completed. "There are hundreds, even thousands of pieces of information communicated relative to the care of patients in an ED every day," says Welch. If the transmission of this information is not well-managed or well-controlled, it limits the efficiency and safety of the ED, she says.
Welch explains that the most important ED-based, care coordination innovations that she has observed involve bringing the patient and the provider together quickly so that patients don't have long, drawn-out pre-process waits. Another innovation worthy of consideration is "split patient flow," in which patients with similar acuities are grouped and cared for in one geographic area by a specific care team, adds Welch.
Volume in the ED should dictate what types of improvements ED managers consider, and all improvement efforts should be data-driven, emphasizes Welch. "ED managers need to understand change management and acquire the skill sets necessary for methodical change and project management," she says.