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A Fresh Approach to Helping High-Needs Patients Who Repeatedly Use the ED

By Dorothy Brooks

What happens when a tiny percentage of patients account for an outsized chunk of ED visits and resources? This is a conundrum with which many EDs are all too familiar. Unfortunately, addressing this problem is difficult.

Staff become frustrated when they see the same patients repeatedly for problems they may not feel empowered to resolve. The patients can feel as though they are caught in an endless cycle that never seems to deliver the kind of care or resources that might make a difference. Realizing a fresh approach was needed, Harris Health System’s Ben Taub Hospital and Lyndon B. Johnson (LBJ) Hospital in Houston implemented a new program. Instead of “frequent flyers” or any other pejorative term, staff call these individuals multivisit patients (MVPs).

This term is part of a methodology through which care providers treat frequent ED visits as a symptom rather than the problem itself.1 Since the MVP program started in fall 2020, Harris Health has recorded 1,700 fewer ED visits annually among MVPs, according to data provided to ED Management. Further, given that the average cost per ED visit in Texas is $2,318, Harris Health has avoided nearly $4 million in excess costs.

Who qualifies as an MVP? Generally, a patient who visits the ED 10 or more times over 12 months. However, Melissa Perez-Halley, LMSW, MA, the population health supervisor who oversees the MVP staff, offers a more nuanced description. “An MVP is a patient who experiences medical, social, and behavioral barriers that have made it difficult for them to navigate the healthcare system, so the system becomes like an additional barrier in that matrix,” she explains.

Through this program, Harris Health tries to address barriers one by one. The process usually begins when the electronic medical record automatically identifies someone as an MVP, based on their record of ED visits. This information is automatically delivered to the MVP staff, which includes four community health workers, two of whom work in the ED at Ben Taub Hospital — a level I trauma center and the larger of the two participating hospitals. One community health worker is stationed in the ED at LBJ Hospital, a level III trauma center. The fourth community health worker splits his or her time between the two EDs.

Together, these staffers review the chart, looking for specific information. For instance, staff will want to know whether the MVP is struggling with housing instability or food insecurity, whether there are any substance use issues, and whether the patient is medically complex. “The most important thing is actually meeting the patient at the bedside [in the ED],” Perez-Halley says.

During this meeting, the community health worker will attempt to learn more detailed information about the patient’s needs and what keeps bringing him or her back to the ED. Staff let the patient lead this conversation, but some are more willing to engage than others. “The community health workers are the experts at navigating personality differences. Sometimes, a physician will work alongside [them] when they are conducting this assessment,” Perez-Halley says.

“What we want is for the community health worker to engage the patient with transparent, consistent messaging, and also help them navigate so that their needs can be met elsewhere,” explains Gregory Buehler, MD, MBA, medical director of the MVP program. “There are not just medical needs, necessarily. In many cases, it is more social needs or behavioral and mental health needs.”

Program administrators note the top drivers of ED use tend to differ between the two departments. For example, at Ben Taub, many MVPs are either unhoused or are living with substance use and/or behavioral health issues. Other MVPs simply prefer receiving their care in the ED.

Alternatively, the MVPs who frequent the LBJ ED tend to be a more socially stable population, but they struggle to navigate the healthcare system. “We’re seeing a lot more patients with inadequate supports and services, or inadequate plans for chronic and recurrent conditions,” Perez-Halley says.

Many MVPs are managing multiple, complex issues, so it may take several visits before there is significant progress. The MVP team has learned to be patient. For example, at one visit, an MVP may be connected with the hospital’s financial assistance program. Next time, a community health worker will link the patient with outpatient medical appointments. “We always try to have a specific, warm handoff process,” Perez-Halley says.

However, in many cases, the MVP staff will need to keep building trust and nurturing their relationships with these patients until they are ready to take action. “We have worked with several patients who we have successfully linked long term with the Houston Recovery Center,” Perez-Halley reports.

While the process can vary from patient to patient, the MVP program has gradually developed what Perez-Halley refers to as care pathways that go along with the different drivers of use. This provides community health workers with a roadmap they can follow as they work with patients who present with different needs.

“This is creating protocols and systems for when someone comes in multiple times, and we get to the diagnosis of an inadequate living environment or a pattern preference,” explains Chethan Bachireddy, MD, MSc, FACP, AAHIVS, senior vice president and chief health officer overseeing population health in the Harris Health System. “It’s creating a pathway from there that is then empowering people in the healthcare setting to really be supportive of patients. It flips on its head the idea that we have systems of care that aren’t serving everybody, and particularly this population.”

From an equity and quality of care standpoint, program administrators report the initiative allows staff to provide person-centered, team-based care to address the most pressing needs of MVPs. They note 80% of MVPs who present to the ED are seen by the MVP team during staff hours, and 90% have created personalized care plans.

Buehler says the relationship between the healthcare team and community healthcare workers has evolved, too. “We share the success stories, and some of these stories involve [patients] who every single person in the ED knows by name,” he says. “The community health workers are seen as problem-solvers.”

As the MVP program has grown, it has strengthened the links between the participating EDs and social service agencies, such as the Coalition for the Homeless of Houston and the Houston Recovery Center, making it easier and more efficient to link patients with needed services. Further, Perez-Halley notes the program is building partnerships with the other hospitals/EDs in the region who also see many of the same high-use patients.

“It is such a dynamic process; it has to be, because once it stagnates the progress with a patient can stop,” she says. “We are building out this whole matrix that works to serve these patients that are relatively few, but really count for the majority of the ED visits to our system.”


1. Zheng Ben Ma, Khatri RP, Buehler G, et al. Transforming care delivery and outcomes for multivisit patients.