Hospitals collaborate to reduce ED overuse

Initiative slashes ED visits, costs

By collaborating on a case management program for uninsured and underinsured patients who overuse the emergency department, two hospitals in Lincoln, NE, have reduced the number of emergency department visits by patients in the program by 56% and cut emergency department costs related to non-emergent care by 67%. In 2011, the initiative saved the two hospitals about $700,000 in uncompensated care costs.

After a 2002 study determined that 36% of patients who used the emergency department at BryanLGH Medical Center could have been better served in the primary care setting, the hospital applied for a grant from the Community Health Endowment, a local organization that funds healthcare improvements in Lincoln.

The organization approved the grant but stipulated that BryanLGH Medical Center collaborate with St. Elizabeth Regional Medical Center to develop the program. After two years of planning, ED Connections began in 2005, says Tom Hoover, RN, MBA, manager of ED Connections. The funding from the grants has ended, but the hospitals have continued to fund the program because it saves enough money to more than pay for itself, Hoover says. The hospitals adapted the Pathways model, which connects at-risk patients to community-based health and social services through the use of pathways designed to produce healthy outcomes.1

The ED Connections staff include Hoover, another RN case manager, and two social workers. One nurse and one social worker are located in offices at each hospital. The ED Connections staff at both hospitals share information and all are cross-trained to work at both hospitals. The entire team meets once a month, reviews the cases, and brainstorms about how to handle the difficult ones.

The majority of patients in the program are women ages 25 to 45 with household incomes below the federal poverty level. The patients have no healthcare coverage because they are either homeless or the working poor. Many have mental health and/or substance abuse problems in addition to physical ailments.

Initially, patients eligible for the program were those who had three or more emergency department visits in six months. "This was shooting ourselves in the foot because if patients couldn't afford their medication, they had to have two more visits because we could intervene and by the third visit, they were so sick, they were in crisis," Hoover says.

Now when patients being treated in the emergency department say they can't afford their medication or have difficulties managing their healthcare, the nurse gives them a card with a telephone number for the ED Connections program as part of their discharge instructions. "There are a lot of requirements for prescription assistance as well as other assistance programs and to do it in the emergency department, it takes up bed space and a lot of time for the clinical staff. By having them call us, we get them to take the first step in becoming responsible for their own healthcare," he says.

The team also gets referrals from community agencies, primary care clinics, and emergency department physicians who place an order for a referral in the electronic medical records.

Identifying patients for the program and setting them up with a medical home is the easy part, Hoover says. "Anybody can help a patient find a medical home and make an appointment. The hard part is overcoming all the baggage they carry with them to prevent them from receiving treatment in a medical home," he adds.

When patients call, the ED Connections staff help them get assistance for their medication or other needed items to care for the acute or chronic condition that brought them to the emergency department. At the same time, staff try to get them to enroll in the program. It's a voluntary program and many patients are not interested in participating, Hoover says.

Once patients agree to enroll in the program, the staff conduct a thorough psychosocial assessment to determine needs and work with the patient to develop an action plan and goals. The patient signs an agreement to comply with the action plan, keep appointments, and become an active participant in his or her healthcare. The team also comes up with a specific plan for the emergency department staff to use when patients present to the emergency department.

The team works closely with the patients, educates them on their chronic illnesses and how to manage them, and helps them get connected to a primary care provider and community resources such as transportation assistance and help with rent or utilities. Everyone on the ED Connections staff is a Social Security disability trained worker for behavioral health. The team has a 93% success rate in getting disability claims approved.

A lot of the contacts are over the telephone, but the staff meet with patients at their physician clinic, at home, or when they come into the ED Connection office at each hospital. "We want them to be responsible and try to get them to come to our office whenever possible," he says.

To provide care for patients with behavioral health and substance abuse issues, the ED Connections team uses cluster-based planning and outcomes management2 which divides the patients into subsets, based on their diagnoses. "We wanted to have a common language among providers since one person's definition of mental health problems often is different from others' definitions, making it extremely confusing for patients and providers," Hoover says.

For instance, adults with serious substance abuse, mental health, and community living problems are grouped into Cluster 2A. If the team is dealing with a homeless, bipolar person who is a substance abuser, the patient would be designated as being in Cluster 2A. "Everybody who works with this patient know what Cluster 2A means, the treatment plan, and the outcomes expectations," he says.

About 75% of patients in the program fit into one of the eight adult clusters.

The team has collaborated with 74 different community service organizations in the Lincoln area to provide resources for patients in the program.

"What we are doing could not happen if not for collaboration between competing hospitals, competing clinics, and competing human services organizations. The initiative has opened up a lot of collaborative programs, not just within the hospitals but in the communities," he says.


  • Tom Hoover, RN, MBA, Manager of ED Connections, BryanLGH Medical Center, Lincoln, NE. email:


  1. For more information on the Pathways Model, see
  2. For more information on cluster-based planning, see the website of Synthesis Inc. and click on Synthesis Services, then cluster-based planning: