ED of future must connect patients, services

It's no longer the gate — now it's the front porch

The emergency department is evolving from being the gate of the hospital to being a front porch for the community, a central location where people with healthcare concerns can come and be triaged to the proper venue for care, says Karen Zander, RN, MS, CCMAC, FAAN, principal and co-owner of The Center for Case Management in Wellesley, MA.

"The emergency department's mantra used to be 'treat 'em and street 'em,' but now we need to be thinking about options to get patients the healthcare they need from whatever point they enter or access the systems and ensure that they don't require readmissions or revisits to the emergency department after discharge," she says.

Insurance companies, physicians, and some hospitals have programs that try to dissuade people from using the emergency department for their primary care needs, but because of many factors in the U.S. society today, it's almost a lost cause, she says.

Not only is there a shortage of primary care doctors, but many doctors won't take patients who are Medicaid beneficiaries, or those who have no insurance, adds Jay Kaplan, MD, FACEP, director of service and operational excellence for CEP America, based in Emeryville, CA, and a member of the board of directors of the American College of Emergency Physicians.

Patients who rely on community clinics for healthcare often experience a delay of several weeks if they are trying to get an appointment, particularly if they're new patients. If they have an acute illness, the only place they can get seen in a timely manner is the emergency department. If they are told to get follow-up care, they often can't get an appointment and end up back in the emergency department.

"The emergency department becomes the de facto primary caregiver for many patients unless they have a case manager to arrange timely follow-up care in another setting where they have more continuity of care," he says.

There's always going to be a need for the emergency department, Zander points out. "We have to get patients to the right level of care, and we should be starting in the emergency department. The emergency department is an integral part of our healthcare system and each of our communities. They should become more a part of the community and be open to the community's changing demographics and healthcare needs, even if people don't need a bed," she says.

Some hospitals are already becoming like "health malls" and locating pharmacies and durable medical equipment stores near their emergency department, she says. Emergency departments are also diversifying into specialty emergency departments, such as those for senior care, pediatrics, and case management services for the complexly ill who have both mental and physical health problems, she says. "They are currently the fastest-changing parts of acute care," she adds.

Zander envisions hospitals having home care representatives, physical therapists, life care planners, health coaches and financial planners located in or near the emergency department to assist patients who do not qualify for acute care but have other needs.

"We need to redefine the hospital as the health and health information source, not just a place for acute care. In the future, hospitals are not going to be able to fill their beds with acute patients because at the rate that change is occurring, many won't meet admission criteria. Hospitals need to continue to create and lobby for services that help people in their communities recover and stay at their highest level of wellness, and that are reimbursed," she says.

People who frequently visit the emergency department often do so because they have nowhere else to go, Kaplan says. "Sometimes people come to the emergency department because of social issues. If we consider alcohol and substance abuse an illness, they are as sick as someone who has pneumonia," he says.

The emergency department has to be considered an integral part of the medical neighborhood, Kaplan says. "We have to look beyond just efficiency of care and the flow of patients within the hospital setting and whether to admit or treat and discharge. We also have to look at the appropriate hand-off in care," he says.

Sometimes emergency department physicians get caught between a rock and a hard place when it comes to admitting patients who can't be safely discharged and who lack other options, Kaplan says. He tells of a 91-year-old woman whose caregiver had resigned and left her with nobody to help her take care of herself. When she came to the emergency department the first time, the physician found out she was alone at home and referred her to social work. The referral fell through the cracks and she came back two days later and ultimately was admitted for a urinary tract infection. "She could have been treated as an outpatient if she had someone to help her care for herself, but with no one at home, she had to be in the hospital," he says.

"We perceive the emergency department is not just the door to the hospital but it's also the porch — the place where people come and sit a bit until they are pointed in the right direction," Kaplan says.